Healthcare Provider Details

I. General information

NPI: 1528397825
Provider Name (Legal Business Name): RANDALL SPEER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2009
Last Update Date: 12/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5109 W BROAD ST
COLUMBUS OH
43228-1648
US

IV. Provider business mailing address

5109 W BROAD ST
COLUMBUS OH
43228-1648
US

V. Phone/Fax

Practice location:
  • Phone: 614-878-9562
  • Fax:
Mailing address:
  • Phone: 614-878-9562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14474
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: