Healthcare Provider Details

I. General information

NPI: 1174512412
Provider Name (Legal Business Name): RANDOLPH CHARLES MYERSON D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 HURLEY AVE
KINGSTON NY
12401-2811
US

IV. Provider business mailing address

149 HURLEY AVE
KINGSTON NY
12401-2811
US

V. Phone/Fax

Practice location:
  • Phone: 845-331-9090
  • Fax: 845-331-7768
Mailing address:
  • Phone: 845-331-9090
  • Fax: 845-331-7768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number034201
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number034201
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: