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General NPI Number Information
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NPI Number | 1902032246
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Entity Type | Organization
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Legal Business Name | RANDALL ORTHODONTICS, P.A.
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Dates
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Enumeration Date | 06/01/2009
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Last Update Date | 06/01/2009
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Provider Practice Location Address
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Address Line | 3285 E. 17TH ST.
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City | AMMON
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State | ID
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Zip | 83406-6758
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Country | US
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Telephone | 208-716-3690
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Fax |
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Provider Business Mailing Address
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Address Line | 3285 E. 17TH ST.
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City | AMMON
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State | ID
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Zip | 83406-6758
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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 | OWNER
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Name | DR. CHARLES JARED RANDALL
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Credential | D.D.S., M.S.
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Telephone | 208-716-3690
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | D-3405-OR
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License Number State | ID
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