MEDICARE: RENITA WALDEN 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	122300000X	Dentist	0401007596	VA

General Provider Information

NPI Number	:	1851422331
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RENITA WALDEN RANDOLPH D.D.S.

Provider Business Mailing Address
First Line	:	13292 KENWICK CT
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23238-6446
Country	:	US
Telephone Number	:	804-317-2227
Fax Number	:

Provider Business Practice Location Address
First Line	:	11551 NUCKOLS RD
Second Line	:	SUITE A
City	:	GLEN ALLEN
State	:	VA
Zip	:	23059-5565
Country	:	US
Telephone Number	:	804-273-6818
Fax Number	:	804-273-0347

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

Provider Enumeration Date	:	03/08/2007
Last Update Date	:	07/08/2007

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