Provider Demographics
NPI:1467522565
Name:COLEMAN, JOHN HENRY (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:HENRY
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 1:1162 S LINE ST
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-4239
Mailing Address - Country:US
Mailing Address - Phone:662-226-0585
Mailing Address - Fax:662-226-0586
Practice Address - Street 1:1162 S LINE ST
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-4239
Practice Address - Country:US
Practice Address - Phone:662-226-0585
Practice Address - Fax:662-226-0586
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS196682122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00064983Medicaid