Provider Demographics
NPI:1407134109
Name:PHILLIPS, ROENIKYA L (DMD, MPH)
Entity Type:Individual
Prefix:MS
First Name:ROENIKYA
Middle Name:L
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:DMD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 S CHRISMAN AVE # 730
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-3316
Mailing Address - Country:US
Mailing Address - Phone:662-801-6863
Mailing Address - Fax:
Practice Address - Street 1:303 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732
Practice Address - Country:US
Practice Address - Phone:662-843-5011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-28
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3607-11122300000X
MSPEDO-535-171223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04753806Medicaid