Provider Demographics
NPI:1063741593
Name:GRILL, RANDALL O (DDS)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:O
Last Name:GRILL
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 1:2328 SW 136TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73170-5143
Mailing Address - Country:US
Mailing Address - Phone:405-590-8331
Mailing Address - Fax:
Practice Address - Street 1:2328 SW 136TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73170-5143
Practice Address - Country:US
Practice Address - Phone:405-590-8331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-11
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOK-55301223G0001X
KS54921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice