Provider Demographics
NPI:1538186069
Name:STUCKI, RANDALL MCKAY (DDS)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:MCKAY
Last Name:STUCKI
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 1:712 CANTERBURY LN
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:UT
Mailing Address - Zip Code:84004-1255
Mailing Address - Country:US
Mailing Address - Phone:801-492-7778
Mailing Address - Fax:
Practice Address - Street 1:75 W MAIN STREET CT STE 200
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:UT
Practice Address - Zip Code:84004-5602
Practice Address - Country:US
Practice Address - Phone:801-492-7778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT145404-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT87-0555800OtherTAX EIN