Provider Demographics
NPI:1194873315
Name:BREEDEN, RANDALL LEE (DDS)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:LEE
Last Name:BREEDEN
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 1:2928 HAMILTON BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51104-2424
Mailing Address - Country:US
Mailing Address - Phone:712-258-3636
Mailing Address - Fax:712-255-4163
Practice Address - Street 1:2928 HAMILTON BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51104-2424
Practice Address - Country:US
Practice Address - Phone:712-258-3636
Practice Address - Fax:712-255-4163
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA081901223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA34813OtherBLUE CROSS
IA0436113Medicaid