Individual
DR. GREGORY MARSHALL RANDOLPH
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
D,D.S.
Contact information
Practice address
119 N WILLIAMSBURG DR, BLOOMINGTON, IL 61704-3528
(309) 663-1326
(309) 662-3551
Mailing address
119 N WILLIAMSBURG DR, BLOOMINGTON, IL 61704-3528
(309) 663-1326
(309) 662-3551
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
019-020416
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
370958381
TAX IDENTIFICATION NUMBER
IL
Enumeration date
02/09/2007
Last updated
04/03/2025
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