Provider Demographics
NPI:1700898392
Name:TERRY, RANDELL S (DMD)
Entity type:Individual
Prefix:DR
First Name:RANDELL
Middle Name:S
Last Name:TERRY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 CORKY BOYD AVE
Mailing Address - Street 2:
Mailing Address - City:WILLS POINT
Mailing Address - State:TX
Mailing Address - Zip Code:75169-2815
Mailing Address - Country:US
Mailing Address - Phone:903-873-2523
Mailing Address - Fax:903-873-4405
Practice Address - Street 1:209 CORKY BOYD AVE
Practice Address - Street 2:
Practice Address - City:WILLS POINT
Practice Address - State:TX
Practice Address - Zip Code:75169-2815
Practice Address - Country:US
Practice Address - Phone:903-873-2523
Practice Address - Fax:903-873-4405
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3994122300000X
TX259291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice