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General NPI Number Information
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NPI Number | 1063741593
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Entity Type | Individual
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Provider Name | RANDALL O GRILL DDS
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Gender | Male
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Dates
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Enumeration Date | 12/11/2009
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Last Update Date | 12/27/2011
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Provider Practice Location Address
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Address Line | 2328 SW 136TH ST
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City | OKLAHOMA CITY
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State | OK
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Zip | 73170-5143
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Country | US
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Telephone | 405-590-8331
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Fax |
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Provider Business Mailing Address
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Address Line | 2328 SW 136TH ST
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City | OKLAHOMA CITY
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State | OK
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Zip | 73170-5143
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Country | US
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Telephone | 405-590-8331
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | OK-5530
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License Number State | OK
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 5492
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License Number State | KS
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