Provider Demographics
NPI:1124244686
Name:STETTLER, RANDALL WAYNE (DDS)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:WAYNE
Last Name:STETTLER
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 1:5565 GROSSMONT CENTER DR
Mailing Address - Street 2:BUILDING 1, SUITE 129
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3020
Mailing Address - Country:US
Mailing Address - Phone:619-463-4486
Mailing Address - Fax:619-463-6553
Practice Address - Street 1:5565 GROSSMONT CENTER DR
Practice Address - Street 2:BUILDING 1, SUITE 129
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3020
Practice Address - Country:US
Practice Address - Phone:619-463-4486
Practice Address - Fax:619-463-6553
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390891223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA39089OtherLICENSE
CA20-5686019OtherEIN