Healthcare Provider Details

I. General information

NPI: 1285841627
Provider Name (Legal Business Name): RANDY T,. MCGOWAN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 LOCUST AVE
AMSTERDAM NY
12010-2623
US

IV. Provider business mailing address

80 LOCUST AVE
AMSTERDAM NY
12010-2623
US

V. Phone/Fax

Practice location:
  • Phone: 519-843-0382
  • Fax: 518-843-0355
Mailing address:
  • Phone: 519-843-0382
  • Fax: 518-843-0355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number037120
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: