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General NPI Number Information
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NPI Number | 1407105760
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Entity Type | Individual
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Provider Name | KELLY ELAINE RANDAZZO R.D.H.A.P
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Gender | Female
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Dates
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Enumeration Date | 09/02/2012
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Last Update Date | 09/02/2012
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Provider Practice Location Address
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Address Line | 12654 NOTTINGHAM DR
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City | RANCHO CUCAMONGA
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State | CA
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Zip | 91739-9168
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Country | US
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Telephone | 909-210-4597
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Fax |
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Provider Business Mailing Address
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Address Line | 12654 NOTTINGHAM DR
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City | RANCHO CUCAMONGA
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State | CA
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Zip | 91739-9168
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Country | US
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Telephone | 909-210-4597
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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 | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number | RDHAP 394
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License Number State | CA
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