Provider Demographics
NPI:1306071758
Name:C. RANDY LANDIS, DDS, INC.
Entity type:Organization
Organization Name:C. RANDY LANDIS, DDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:RANDY
Authorized Official - Last Name:LANDIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,OMS
Authorized Official - Phone:530-893-3912
Mailing Address - Street 1:80 DECLARATION DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95973-4913
Mailing Address - Country:US
Mailing Address - Phone:530-893-3912
Mailing Address - Fax:530-893-2451
Practice Address - Street 1:80 DECLARATION DR
Practice Address - Street 2:SUITE 101
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95973-4913
Practice Address - Country:US
Practice Address - Phone:530-893-3912
Practice Address - Fax:530-893-2451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-28
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA319401223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB31940Medicaid
CADS0319400Medicare PIN