Provider Demographics
NPI:1053437012
Name:WOOLBRIGHT, RANDOL OLEN JR (DDS)
Entity type:Individual
Prefix:DR
First Name:RANDOL
Middle Name:OLEN
Last Name:WOOLBRIGHT
Suffix:JR
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 1:214 E MCCLAIN AVE
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47170-1824
Mailing Address - Country:US
Mailing Address - Phone:812-752-7745
Mailing Address - Fax:812-752-5543
Practice Address - Street 1:214 E MCCLAIN AVE
Practice Address - Street 2:
Practice Address - City:SCOTTSBURG
Practice Address - State:IN
Practice Address - Zip Code:47170-1824
Practice Address - Country:US
Practice Address - Phone:812-752-7745
Practice Address - Fax:812-752-5543
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008633A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100221370AMedicaid