Basic Information
| Provider Information | |||||||||
| NPI: | 1023228319 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOVE | ||||||||
| FirstName: | RANDY | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 588 | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390460588 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018595213 | ||||||||
| FaxNumber: | 6018598771 | ||||||||
| Practice Location | |||||||||
| Address1: | 1668 W PEACE ST | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390465332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018595213 | ||||||||
| FaxNumber: | 6018598771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 1934 81 | MS | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 01689068 | 05 | MS | MEDICAID |