Healthcare Provider Details

I. General information

NPI: 1447310925
Provider Name (Legal Business Name): RANDALL MADSEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7138 S HIGHLAND DR #109
SALT LAKE CITY UT
84121
US

IV. Provider business mailing address

7138 S HIGHLAND DR #109
SALT LAKE CITY UT
84121
US

V. Phone/Fax

Practice location:
  • Phone: 801-942-8686
  • Fax: 801-942-7652
Mailing address:
  • Phone: 801-942-8686
  • Fax: 801-942-7652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number5639652
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: