Individual
DR. CHARLES JARED RANDALL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
3285 E. 17TH ST., AMMON, ID 83406-6758
(208) 523-3380
(208) 523-3077
Mailing address
3285 E. 17TH ST., AMMON, ID 83406-6758
(208) 523-3380
(208) 523-3077
Taxonomy
Speciality
Code
Description
License number
State
1223X0400X
Orthodontics and Dentofacial Orthopedics Dentistry
Primary
D-3405-OR
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
806122100
—
ID
Enumeration date
01/08/2007
Last updated
07/24/2009
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