Provider Demographics
NPI:1487781605
Name:DAVIS, RANDALL L
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:L
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:RANDALL
Other - Middle Name:L
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:100 AMESBURY ST STE 203
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01840-1321
Mailing Address - Country:US
Mailing Address - Phone:978-686-8500
Mailing Address - Fax:978-686-4032
Practice Address - Street 1:100 AMESBURY ST STE 203
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01840-1321
Practice Address - Country:US
Practice Address - Phone:978-686-8500
Practice Address - Fax:978-686-4032
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16356122300000X, 1223G0001X, 1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
No1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0280178Medicaid
MA0280178Medicaid