Healthcare Provider Details

I. General information

NPI: 1700898392
Provider Name (Legal Business Name): RANDELL S. TERRY DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 02/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 CORKY BOYD AVE
WILLS POINT TX
75169-2815
US

IV. Provider business mailing address

209 CORKY BOYD AVE
WILLS POINT TX
75169-2815
US

V. Phone/Fax

Practice location:
  • Phone: 903-873-2523
  • Fax: 903-873-4405
Mailing address:
  • Phone: 903-873-2523
  • Fax: 903-873-4405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD3994
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number25929
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: