Provider Demographics
NPI:1679623557
Name:MONNES, RANDALL J (DMD)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:J
Last Name:MONNES
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 NE 2ND ST
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-7512
Mailing Address - Country:US
Mailing Address - Phone:503-665-8283
Mailing Address - Fax:503-669-7263
Practice Address - Street 1:915 NE 2ND ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7512
Practice Address - Country:US
Practice Address - Phone:503-665-8283
Practice Address - Fax:503-669-7263
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD62371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice