Provider Demographics
NPI:1346329166
Name:TOM, RODNEY DARRYL (DMD)
Entity Type:Individual
Prefix:DR
First Name:RODNEY
Middle Name:DARRYL
Last Name:TOM
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 1:116 PLEASANT HOME RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907-3518
Mailing Address - Country:US
Mailing Address - Phone:706-868-9630
Mailing Address - Fax:706-868-1008
Practice Address - Street 1:116 PLEASANT HOME RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907-3518
Practice Address - Country:US
Practice Address - Phone:706-868-9630
Practice Address - Fax:706-868-1008
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA105761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice