College Avenue Dental Sleep Appliances LTD.

Key facts

NPI

1962829366

Entity type

Organization (NPI type 2)

Primary specialty

Durable Medical Equipment & Medical Supplies 332B00000X

License

019019857 (IL)

Legal business name

COLLEGE AVENUE DENTAL SLEEP APPLIANCES LTD.

Practice address

505 W College Ave
Jacksonville, IL 62650-2405

Phone

(217) 245-5313

Fax

(217) 383-0204

NPI assigned

Mar 24, 2014

Organization subpart

No

Authorized official

Name

Randall Evert Lawson, DDS NPI 1730151176

Title

Owner

Phone

(217) 473-6758

Authorized official NPPES reports the authorized official by name only; the link goes to the one practitioner connected to this organization with that name.

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Randall Evert Lawson, D.D.S. General Practice Dentistry · Jacksonville, IL · NPI 1730151176
  NPD Authorized official

Medicare participation

Medicare fee-for-service enrollment

Enrolled in IL

Medicare enrollment records

National Provider Directory

Locations

Specialties & licenses

Addresses

Other names

• Randall E Lawson DDS Other name

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Apr 22, 2014.

{
    "created_epoch": "1395619200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1398124800000",
    "number": "1962829366",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "505 W COLLEGE AVE",
            "city": "JACKSONVILLE",
            "state": "IL",
            "postal_code": "626502405",
            "telephone_number": "217-245-5313",
            "fax_number": "217-383-0204"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "505 W COLLEGE AVE",
            "city": "JACKSONVILLE",
            "state": "IL",
            "postal_code": "626502405",
            "telephone_number": "217-245-5313",
            "fax_number": "217-383-0204"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COLLEGE AVENUE DENTAL SLEEP APPLIANCES LTD.",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-03-24",
        "last_updated": "2014-04-22",
        "status": "A",
        "authorized_official_last_name": "LAWSON",
        "authorized_official_first_name": "RANDALL",
        "authorized_official_middle_name": "EVERT",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "217-473-6758",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": "IL",
            "license": "019019857",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Randall E Lawson DDS",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

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