Healthcare Provider Details

I. General information

NPI: 1609896182
Provider Name (Legal Business Name): HARRY RANDEL D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9892 BUSTLETON AVE SUITE 304
PHILADELPHIA PA
19115-2184
US

IV. Provider business mailing address

9892 BUSTLETON AVE SUITE 304
PHILADELPHIA PA
19115-2184
US

V. Phone/Fax

Practice location:
  • Phone: 215-673-0123
  • Fax: 215-673-0266
Mailing address:
  • Phone: 215-673-0123
  • Fax: 215-673-0266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDS023529L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: