Provider Demographics
NPI:1588326235
Name:MCHENRY, RANDY ALLEN (LD)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:ALLEN
Last Name:MCHENRY
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8707 JACKRABBIT LN STE C
Mailing Address - Street 2:
Mailing Address - City:BELGRADE
Mailing Address - State:MT
Mailing Address - Zip Code:59714-8995
Mailing Address - Country:US
Mailing Address - Phone:406-813-8551
Mailing Address - Fax:
Practice Address - Street 1:8707 JACKRABBIT LN STE C
Practice Address - Street 2:
Practice Address - City:BELGRADE
Practice Address - State:MT
Practice Address - Zip Code:59714-8995
Practice Address - Country:US
Practice Address - Phone:406-813-8551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-11
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT21586122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist