Provider Demographics
NPI:1699772509
Name:STASTNY, RANDALL DAVID (DMD)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:DAVID
Last Name:STASTNY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4350 MALSBARY RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BLUE ASH
Mailing Address - State:OH
Mailing Address - Zip Code:45242-5665
Mailing Address - Country:US
Mailing Address - Phone:513-984-2100
Mailing Address - Fax:513-984-2155
Practice Address - Street 1:4350 MALSBARY RD
Practice Address - Street 2:SUITE 201
Practice Address - City:BLUE ASH
Practice Address - State:OH
Practice Address - Zip Code:45242-5665
Practice Address - Country:US
Practice Address - Phone:513-984-2100
Practice Address - Fax:513-984-2155
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-1-88921223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH11892OtherHUMANA
OHU33772Medicare UPIN
OHST0742746Medicare PIN