MEDICARE: RANDOM LAKE DENTISTRY, INC

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1982421046
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RANDOM LAKE DENTISTRY, INC

Provider Business Mailing Address
First Line	:	62 S PLEASANT VIEW RD
Second Line	:
City	:	PLYMOUTH
State	:	WI
Zip	:	53073-4954
Country	:	US
Telephone Number	:	920-892-8466
Fax Number	:	920-892-8467

Provider Business Practice Location Address
First Line	:	37 HICKORY DR
Second Line	:
City	:	RANDOM LAKE
State	:	WI
Zip	:	53075-1675
Country	:	US
Telephone Number	:	920-994-4367
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. HOOMAN ABDOLISERESHKI
Credential	:	D.D.S
Telephone Number	:	920-892-8466

Provider Enumeration Date	:	09/20/2024
Last Update Date	:	09/20/2024

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