MEDICARE: ELIZABETH FELTS RANDALL D.M.D.

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	1223P0300X	Periodontics	5960C1	AL
2	1223P0300X	Periodontics	9462	TN

General Provider Information

NPI Number	:	1891042461
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH FELTS RANDALL D.M.D.

Provider Business Mailing Address
First Line	:	951 RIVERFRONT PKWY
Second Line	:	SUITE 102
City	:	CHATTANOOGA
State	:	TN
Zip	:	37402-2185
Country	:	US
Telephone Number	:	423-756-2450
Fax Number	:	423-756-5451

Provider Business Practice Location Address
First Line	:	951 RIVERFRONT PKWY
Second Line	:	SUITE 102
City	:	CHATTANOOGA
State	:	TN
Zip	:	37402-2185
Country	:	US
Telephone Number	:	423-756-2450
Fax Number	:	423-756-5451

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

Provider Enumeration Date	:	08/13/2012
Last Update Date	:	04/12/2015

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