Provider Demographics
NPI:1033249867
Name:COLEMAN, RODERICK L (DMD)
Entity Type:Individual
Prefix:
First Name:RODERICK
Middle Name:L
Last Name:COLEMAN
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 1:120 HOLT COLLIER DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39183-4408
Mailing Address - Country:US
Mailing Address - Phone:601-619-4777
Mailing Address - Fax:601-619-4667
Practice Address - Street 1:120 HOLT COLLIER DR
Practice Address - Street 2:SUITE D
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183-4408
Practice Address - Country:US
Practice Address - Phone:601-619-4777
Practice Address - Fax:601-619-4667
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3153-001223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660349Medicaid
MS02988820Medicaid