Healthcare Provider Details

I. General information

NPI: 1194934224
Provider Name (Legal Business Name): RANDY J O'LAUGHLIN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 S MANITOU ST
PINCONNING MI
48650-9350
US

IV. Provider business mailing address

PO BOX 806
PINCONNING MI
48650-0806
US

V. Phone/Fax

Practice location:
  • Phone: 989-879-4721
  • Fax: 989-879-4731
Mailing address:
  • Phone: 989-879-4721
  • Fax: 989-879-4731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number13187
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: