Provider Demographics
NPI:1033293311
Name:ROGER A. WRIGHT, D. M. D., DENTAL CLINIC, INC.
Entity Type:Organization
Organization Name:ROGER A. WRIGHT, D. M. D., DENTAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN OF THE BOARD
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:D M D
Authorized Official - Phone:662-369-2063
Mailing Address - Street 1:513 W COMMERCE ST
Mailing Address - Street 2:P. O. BOX 212
Mailing Address - City:ABERDEEN
Mailing Address - State:MS
Mailing Address - Zip Code:39730-2543
Mailing Address - Country:US
Mailing Address - Phone:662-369-2063
Mailing Address - Fax:662-369-2076
Practice Address - Street 1:513 W COMMERCE ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:MS
Practice Address - Zip Code:39730-2543
Practice Address - Country:US
Practice Address - Phone:662-369-2063
Practice Address - Fax:662-369-2076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1860-791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00064708Medicaid