Healthcare Provider Details

I. General information

NPI: 1265416242
Provider Name (Legal Business Name): RANDALL N DEATON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

518 E MAIN ST
ADAMSVILLE TN
38310-0321
US

IV. Provider business mailing address

PO BOX 321 518 E MAIN ST
ADAMSVILLE TN
38310-0321
US

V. Phone/Fax

Practice location:
  • Phone: 731-632-3371
  • Fax: 731-632-5443
Mailing address:
  • Phone: 731-632-3371
  • Fax: 731-632-5443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS006949
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: