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General NPI Number Information
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NPI Number | 1124459169
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Entity Type | Individual
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Provider Name | AMELIA RANDOLPH DMD, MS
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Gender | Female
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Dates
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Enumeration Date | 12/02/2013
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Last Update Date | 12/02/2013
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Provider Practice Location Address
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Address Line | 1779 SW BARNETT WAY
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City | LAKE CITY
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State | FL
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Zip | 32025-6957
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Country | US
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Telephone | 386-755-4033
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Fax |
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Provider Business Mailing Address
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Address Line | 1779 SW BARNETT WAY
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City | LAKE CITY
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State | FL
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Zip | 32025-6957
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Country | US
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Telephone |
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | FR3349669
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License Number State | FL
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