Healthcare Provider Details

I. General information

NPI: 1801143110
Provider Name (Legal Business Name): RANDLE DENTAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2012
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10109 US HWY 12
RANDLE WA
98377
US

IV. Provider business mailing address

P.O. BOX 248
RANDLE WA
98377-0248
US

V. Phone/Fax

Practice location:
  • Phone: 360-497-5741
  • Fax: 360-497-5744
Mailing address:
  • Phone: 360-497-5741
  • Fax: 360-497-5744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDE60298156
License Number StateWA

VIII. Authorized Official

Name: DR. RYAN LEMERT
Title or Position: DENTIST
Credential: DMD
Phone: 360-497-5741