Provider Demographics
NPI:1811990807
Name:RAETZ, RANDY GORDON (DDS)
Entity type:Individual
Prefix:DR
First Name:RANDY
Middle Name:GORDON
Last Name:RAETZ
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 1:2273 S CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-2662
Mailing Address - Country:US
Mailing Address - Phone:585-473-1550
Mailing Address - Fax:585-473-1552
Practice Address - Street 1:2273 S CLINTON AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-2662
Practice Address - Country:US
Practice Address - Phone:585-473-1550
Practice Address - Fax:585-473-1552
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0458871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice