Provider Demographics
NPI:1902983497
Name:TOM, RANDALL WILLIAM (DDS)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:WILLIAM
Last Name:TOM
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 1:1268 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94122-1724
Mailing Address - Country:US
Mailing Address - Phone:415-681-4291
Mailing Address - Fax:
Practice Address - Street 1:1268 20TH AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94122-1724
Practice Address - Country:US
Practice Address - Phone:415-681-4291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADH33862122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist