Provider Demographics
NPI:1730184334
Name:MITCHELL, RANDOLPH L (DMD)
Entity type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:L
Last Name:MITCHELL
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 1:47 WILLIAM ST
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:NY
Mailing Address - Zip Code:14489-1544
Mailing Address - Country:US
Mailing Address - Phone:315-946-6511
Mailing Address - Fax:315-946-6483
Practice Address - Street 1:47 WILLIAM ST
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:NY
Practice Address - Zip Code:14489-1544
Practice Address - Country:US
Practice Address - Phone:315-946-6511
Practice Address - Fax:315-946-6483
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0371921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice