Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223P0221X | Pediatric Dentist | 30018784 | OH |
Y | 1223P0221X | Pediatric Dentist | 39055 | CA |
NPI | 1023118072 |
---|---|
Provider Name | Dr. Randall Eugene Niederkohr |
First Address | Los Angeles, CA 90004 |
Second Address | Los Angeles, CA 90004 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/09/2006 |
Last Update Date | 08/07/2007 |