Provider Demographics
NPI:1043556046
Name:BALDWIN, RANDALL GLENN (DMD)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:GLENN
Last Name:BALDWIN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 E RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06877-5017
Mailing Address - Country:US
Mailing Address - Phone:203-438-5174
Mailing Address - Fax:
Practice Address - Street 1:42 DANBURY RD
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD
Practice Address - State:CT
Practice Address - Zip Code:06877-4019
Practice Address - Country:US
Practice Address - Phone:203-438-7181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-19
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTDO 4074122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist