=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033325014
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RANDALL S PERRY DDS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2007
-----------------------------------------------------
Last Update Date | 06/12/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1132 DAVIE AVE
-----------------------------------------------------
City | STATESVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28677
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-881-0990
-----------------------------------------------------
Fax | 704-872-8541
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1132 DAVIE AVE
-----------------------------------------------------
City | STATESVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28677
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-881-0990
-----------------------------------------------------
Fax | 704-872-8541
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. RANDALL SCOTT PERRY
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 704-881-0990
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 6074
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------