Provider Demographics
NPI:1043752074
Name:RANDOLPH SMILES LLC
Entity type:Organization
Organization Name:RANDOLPH SMILES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:RAMESH
Authorized Official - Middle Name:
Authorized Official - Last Name:IZEDIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:508-676-8268
Mailing Address - Street 1:673 ROBESON STREET
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02720
Mailing Address - Country:US
Mailing Address - Phone:508-676-8268
Mailing Address - Fax:
Practice Address - Street 1:56 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:MA
Practice Address - Zip Code:02368
Practice Address - Country:US
Practice Address - Phone:508-676-8268
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-08
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18174122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA280712Medicaid