Healthcare Provider Details

I. General information

NPI: 1467571612
Provider Name (Legal Business Name): RANDY L TOWNSEND LD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1228 MAIN ST
SWEET HOME OR
97386-1608
US

IV. Provider business mailing address

1228 MAIN ST
SWEET HOME OR
97386-1608
US

V. Phone/Fax

Practice location:
  • Phone: 541-409-2499
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License NumberDTDO629849
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: