Provider Demographics
NPI:1760207658
Name:RANDOLPH, SANDRA (RDH, OMT)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:RDH, OMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 238
Mailing Address - Street 2:
Mailing Address - City:BELFRY
Mailing Address - State:MT
Mailing Address - Zip Code:59008-0238
Mailing Address - Country:US
Mailing Address - Phone:253-226-6220
Mailing Address - Fax:
Practice Address - Street 1:52 CRAZY HORSE LN
Practice Address - Street 2:
Practice Address - City:BELFRY
Practice Address - State:MT
Practice Address - Zip Code:59008-9510
Practice Address - Country:US
Practice Address - Phone:406-201-8259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-18
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist