Provider Demographics
NPI:1699785063
Name:RANDY WRIGHT, DDS, MS, LLC
Entity type:Organization
Organization Name:RANDY WRIGHT, DDS, MS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:RANDALL
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:630-208-1200
Mailing Address - Street 1:1460 KEIM CIR
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-7516
Mailing Address - Country:US
Mailing Address - Phone:630-208-7776
Mailing Address - Fax:
Practice Address - Street 1:2550 W FABYAN PKWY
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:IL
Practice Address - Zip Code:60510-1572
Practice Address - Country:US
Practice Address - Phone:630-208-1200
Practice Address - Fax:630-402-0378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190241451223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty