MEDICARE: MR. RANDALL B MAYBERRY 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	122300000X	Dentist	D8549	OR

General Provider Information

NPI Number	:	1336134055
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RANDALL B MAYBERRY DDS

Provider Business Mailing Address
First Line	:	893 ROSEMONT CT
Second Line	:
City	:	KLAMATH FALLS
State	:	OR
Zip	:	97603-7154
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2074 S 6TH ST
Second Line	:
City	:	KLAMATH FALLS
State	:	OR
Zip	:	97601-3372
Country	:	US
Telephone Number	:	541-851-8110
Fax Number	:	541-851-8114

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

Provider Enumeration Date	:	09/19/2005
Last Update Date	:	03/07/2023

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