Healthcare Provider Details

I. General information

NPI: 1598731697
Provider Name (Legal Business Name): C. RANDALL DOAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 02/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1456 KADERLY ST NW
NEW PHILADELPHIA OH
44663-1243
US

IV. Provider business mailing address

1456 KADERLY ST NW
NEW PHILADELPHIA OH
44663-1243
US

V. Phone/Fax

Practice location:
  • Phone: 330-364-8665
  • Fax: 330-364-8667
Mailing address:
  • Phone: 330-364-8665
  • Fax: 330-364-8667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number15013
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number15013
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: