=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306071758
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | C. RANDY LANDIS, DDS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2009
-----------------------------------------------------
Last Update Date | 11/03/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 80 DECLARATION DR SUITE 101
-----------------------------------------------------
City | CHICO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95973-4913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-893-3912
-----------------------------------------------------
Fax | 530-893-2451
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 80 DECLARATION DR SUITE 101
-----------------------------------------------------
City | CHICO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95973-4913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-893-3912
-----------------------------------------------------
Fax | 530-893-2451
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | CHARLES RANDY LANDIS
-----------------------------------------------------
Credential | DDS,OMS
-----------------------------------------------------
Telephone | 530-893-3912
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 31940
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------