MEDICARE: DR. BRADLEY A RANDOLPH D.D.S.

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	07810	IA

General Provider Information

NPI Number	:	1497757546
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRADLEY A RANDOLPH D.D.S.

Provider Business Mailing Address
First Line	:	320 N 3RD ST
Second Line	:	STE 711
City	:	BURLINGTON
State	:	IA
Zip	:	52601-5308
Country	:	US
Telephone Number	:	319-753-1600
Fax Number	:	319-752-9453

Provider Business Practice Location Address
First Line	:	320 N 3RD ST
Second Line	:	STE 711
City	:	BURLINGTON
State	:	IA
Zip	:	52601-5308
Country	:	US
Telephone Number	:	319-753-1600
Fax Number	:	319-752-9453

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

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	07/08/2007

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