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NPI Code Detail

MEDICARE: DAVID F RANDOLPH DMD PA

MEDICARE: DAVID F RANDOLPH DMD PA
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
1122300000XDentist9899FL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
160390OTHERFLBLUE CROSS BLUE SHIELD

General Provider Information

NPI Number : 1528189446
Entity Type Code : Organization
Provider Name (Legal Business Name) : DAVID F RANDOLPH DMD PA
Provider Business Mailing Address
First Line : 1779 SW BARNETT WAY STE 101
Second Line :
City : LAKE CITY
State : FL
Zip : 32025-6957
Country : US
Telephone Number : 386-755-4033
Fax Number : 386-755-2581
Provider Business Practice Location Address
First Line : 1779 SW BARNETT WAY STE 101
Second Line :
City : LAKE CITY
State : FL
Zip : 32025-6957
Country : US
Telephone Number : 386-755-4033
Fax Number : 386-755-2581
Authorized Official
Title or Position : DENTIST
Name : DAVID F RANDOLPH
Credential :
Telephone Number : 386-755-4033
Provider Enumeration Date : 04/02/2007
Last Update Date : 09/23/2009

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Directions to “DAVID F RANDOLPH DMD PA ” Practice Location

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