Provider Demographics
NPI:1548474711
Name:WILEY, RANDALL R (DDS)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:R
Last Name:WILEY
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 1:2879 WILLOW PASS RD
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94519-2553
Mailing Address - Country:US
Mailing Address - Phone:925-685-0513
Mailing Address - Fax:
Practice Address - Street 1:2879 WILLOW PASS RD
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94519-2553
Practice Address - Country:US
Practice Address - Phone:925-685-0513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA212251223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry