=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558456368
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RANDY A. BARONE, DDS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2006
-----------------------------------------------------
Last Update Date | 05/14/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 250 W COUNTRY CLUB RD
-----------------------------------------------------
City | ROSWELL
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88201-5250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-623-4161
-----------------------------------------------------
Fax | 575-623-4144
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 250 W COUNTRY CLUB RD
-----------------------------------------------------
City | ROSWELL
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88201-5250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-623-4161
-----------------------------------------------------
Fax | 575-623-4144
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. TAMMY BARONE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 575-623-4161
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DD1910
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------