Provider Demographics
NPI:1174624746
Name:BAETZ, RANDALL WILLIAM (DDS)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:WILLIAM
Last Name:BAETZ
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 1:7150 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-2068
Mailing Address - Country:US
Mailing Address - Phone:248-625-4455
Mailing Address - Fax:248-625-2942
Practice Address - Street 1:7150 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-2068
Practice Address - Country:US
Practice Address - Phone:248-625-4455
Practice Address - Fax:248-625-2942
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901011004122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist