Provider Demographics
NPI:1447310925
Name:MADSEN, RANDALL (DDS)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:
Last Name:MADSEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7138 S HIGHLAND DR
Mailing Address - Street 2:#109
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121
Mailing Address - Country:US
Mailing Address - Phone:801-942-8686
Mailing Address - Fax:801-942-7652
Practice Address - Street 1:7138 S HIGHLAND DR
Practice Address - Street 2:#109
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121
Practice Address - Country:US
Practice Address - Phone:801-942-8686
Practice Address - Fax:801-942-7652
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT56396521223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics