Basic Information
| Provider Information | |||||||||
| NPI: | 1609072750 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARLTON | ||||||||
| FirstName: | RANDALL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2435 | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 764308020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3258934010 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1712 N ACCESS RD | ||||||||
| Address2: | |||||||||
| City: | CLYDE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 795103352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3258934010 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2007 | ||||||||
| LastUpdateDate: | 07/15/2016 | ||||||||
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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 | 23368 | TX | Y | Dental Providers | Dentist | 1223G0001X | 23368 | TX | N | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 196489211 | 05 | TX | MEDICAID | 196489202 | 05 | TX | MEDICAID |