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General NPI Number Information
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NPI Number | 1295896942
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Entity Type | Organization
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Legal Business Name | GREGORY T RANDALL DDS PC
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Dates
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Enumeration Date | 12/13/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 212 W STATE ROAD
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City | HASTINGS
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State | MI
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Zip | 49058
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Country | US
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Telephone | 269-948-6684
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Fax | 269-948-4644
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Provider Business Mailing Address
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Address Line | 212 W STATE ROAD STE A
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City | HASTINGS
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State | MI
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Zip | 49058
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Country | US
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Telephone | 269-948-6684
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Fax | 269-948-4644
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. GREGORY THOMAS RANDALL
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Credential | DDS
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Telephone | 269-948-6684
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number | 017159
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License Number State | MI
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