Provider Demographics
NPI:1174529390
Name:BROWN, RANDALL C (DMD)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:C
Last Name:BROWN
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 1:902 W 25TH ST
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-4236
Mailing Address - Country:US
Mailing Address - Phone:407-323-5650
Mailing Address - Fax:
Practice Address - Street 1:902 W 25TH ST
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-4236
Practice Address - Country:US
Practice Address - Phone:407-323-5650
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL72101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice