Provider Demographics
NPI:1366599656
Name:MONROE, RANDALL HOWARD (DDS)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:HOWARD
Last Name:MONROE
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 1:500 E SOUTHERN AVE STE A
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-5210
Mailing Address - Country:US
Mailing Address - Phone:480-967-3303
Mailing Address - Fax:480-967-0354
Practice Address - Street 1:500 E SOUTHERN AVE STE A
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-5210
Practice Address - Country:US
Practice Address - Phone:480-967-3303
Practice Address - Fax:480-967-0354
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ35301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ3530OtherSTATE LICENSE NUMBER