Provider Demographics
NPI:1063766251
Name:RANDY ALLEN CASTLE DMD, PC
Entity type:Organization
Organization Name:RANDY ALLEN CASTLE DMD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:CASTLE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-701-0191
Mailing Address - Street 1:2350 SW MULTNOMAH BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-3999
Mailing Address - Country:US
Mailing Address - Phone:503-245-3515
Mailing Address - Fax:503-257-3722
Practice Address - Street 1:2350 SW MULTNOMAH BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-3999
Practice Address - Country:US
Practice Address - Phone:503-245-3515
Practice Address - Fax:503-257-3722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-09
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9350261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental