MEDICARE: RANDOLPH L LAIS DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	3304	AR

General Provider Information

NPI Number	:	1003941857
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RANDOLPH L LAIS DDS

Provider Business Mailing Address
First Line	:	5508 PINNACLE POINT DR
Second Line	:
City	:	ROGERS
State	:	AR
Zip	:	72758-8143
Country	:	US
Telephone Number	:	479-845-1225
Fax Number	:	479-845-1227

Provider Business Practice Location Address
First Line	:	5508 PINNACLE POINT DR
Second Line	:
City	:	ROGERS
State	:	AR
Zip	:	72758-8143
Country	:	US
Telephone Number	:	479-845-1225
Fax Number	:	479-845-1227

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/22/2007
Last Update Date	:	07/08/2007

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