Provider Demographics
NPI:1447282330
Name:RANDALL, GREGORY J (DMD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:J
Last Name:RANDALL
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 1:4358 PHEASANT RIDGE TRL
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-4977
Mailing Address - Country:US
Mailing Address - Phone:801-362-5165
Mailing Address - Fax:
Practice Address - Street 1:9141 VILLAGE SHOP DR
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-7722
Practice Address - Country:US
Practice Address - Phone:801-727-2626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6986809-9921122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist