Provider Demographics
NPI:1497843445
Name:BLAZIC, RANDALL J (DDS MD)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:J
Last Name:BLAZIC
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Gender:
Credentials:DDS MD
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Mailing Address - Street 1:13980 W AVALON DR STE 120
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-1404
Mailing Address - Country:US
Mailing Address - Phone:623-935-5774
Mailing Address - Fax:623-935-6524
Practice Address - Street 1:13980 W AVALON DR STE 120
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-1404
Practice Address - Country:US
Practice Address - Phone:623-935-5774
Practice Address - Fax:623-935-6524
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2025-04-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZM31657204E00000X
AZD59761223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery