Provider Demographics
NPI:1932530656
Name:RANDALLL DAVIS MDM PC
Entity type:Organization
Organization Name:RANDALLL DAVIS MDM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:REYNA
Authorized Official - Middle Name:E
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-686-8500
Mailing Address - Street 1:14 MYRTLE ST
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02145-4312
Mailing Address - Country:US
Mailing Address - Phone:857-498-1353
Mailing Address - Fax:
Practice Address - Street 1:14 MYRTLE ST
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02145-4312
Practice Address - Country:US
Practice Address - Phone:857-498-1353
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-05
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1856426122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty