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General NPI Number Information
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NPI Number | 1932119161
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Entity Type | Organization
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Legal Business Name | RANDY L. SORENSEN DMD PA
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Dates
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Enumeration Date | 08/09/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 939 BRYDEN AVE
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City | LEWISTON
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State | ID
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Zip | 83501-5057
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Country | US
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Telephone | 208-746-2668
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Fax |
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Provider Business Mailing Address
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Address Line | 939 BRYDEN AVE
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City | LEWISTON
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State | ID
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Zip | 83501-5057
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Country | US
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Telephone | 208-746-2668
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. RANDY LEE SORENSEN
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Credential | DMD
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Telephone | 208-746-2668
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D3092
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License Number State | ID
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