MEDICARE: DR. RANDELL S. TERRY DMD

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	D3994	ID
2	1223G0001X	General Practice Dentistry	25929	TX

General Provider Information

NPI Number	:	1700898392
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RANDELL S. TERRY DMD

Provider Business Mailing Address
First Line	:	209 CORKY BOYD AVE
Second Line	:
City	:	WILLS POINT
State	:	TX
Zip	:	75169-2815
Country	:	US
Telephone Number	:	903-873-2523
Fax Number	:	903-873-4405

Provider Business Practice Location Address
First Line	:	209 CORKY BOYD AVE
Second Line	:
City	:	WILLS POINT
State	:	TX
Zip	:	75169-2815
Country	:	US
Telephone Number	:	903-873-2523
Fax Number	:	903-873-4405

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

Provider Enumeration Date	:	08/12/2006
Last Update Date	:	02/09/2011

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