Provider Demographics
NPI:1609996461
Name:PATTERSON, ROOSEVELT
Entity Type:Individual
Prefix:
First Name:ROOSEVELT
Middle Name:
Last Name:PATTERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7413 WHITESVILLE RD.
Mailing Address - Street 2:SUITE 400 B
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904
Mailing Address - Country:US
Mailing Address - Phone:706-256-1213
Mailing Address - Fax:706-256-1417
Practice Address - Street 1:7413 WHITESVILLE RD
Practice Address - Street 2:SUITE 400 B
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-3227
Practice Address - Country:US
Practice Address - Phone:706-256-1213
Practice Address - Fax:706-256-1417
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN00110301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice