Provider Demographics
NPI:1710130141
Name:WOMACK, ROLAND E (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROLAND
Middle Name:E
Last Name:WOMACK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 SUTTER ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:CA
Mailing Address - Zip Code:95642
Mailing Address - Country:US
Mailing Address - Phone:209-223-0204
Mailing Address - Fax:
Practice Address - Street 1:511 SUTTER ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95642
Practice Address - Country:US
Practice Address - Phone:209-223-0204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-29
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA036853122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist