Provider Demographics
NPI:1902084163
Name:RANDALL O DUCK DDS PA
Entity Type:Organization
Organization Name:RANDALL O DUCK DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:OWEN
Authorized Official - Last Name:DUCK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:336-760-2500
Mailing Address - Street 1:3744 VEST MILL RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-2912
Mailing Address - Country:US
Mailing Address - Phone:336-760-2501
Mailing Address - Fax:336-760-2192
Practice Address - Street 1:3744 VEST MILL RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2912
Practice Address - Country:US
Practice Address - Phone:336-760-2501
Practice Address - Fax:336-760-2192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-09
Last Update Date:2008-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4630261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental