Provider Demographics
NPI:1306268016
Name:PERRY, RANDALL SCOTT (DDS)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:SCOTT
Last Name:PERRY
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 1:1132 DAVIE AVENUE
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28677
Mailing Address - Country:US
Mailing Address - Phone:704-881-0990
Mailing Address - Fax:704-872-8541
Practice Address - Street 1:1132 DAVIE AVENUE
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677
Practice Address - Country:US
Practice Address - Phone:704-881-0990
Practice Address - Fax:704-872-8541
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-15
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6074122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1033325014OtherNPI TYPE II
NCU50371Medicare UPIN
NC2428570Medicare PIN