Provider Demographics
NPI:1962686394
Name:RODERICK L. COLEMAN, D.M.D., PA
Entity Type:Organization
Organization Name:RODERICK L. COLEMAN, D.M.D., PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RODERICK
Authorized Official - Middle Name:L
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-619-4777
Mailing Address - Street 1:120 HOLT COLLIER DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39183-4408
Mailing Address - Country:US
Mailing Address - Phone:601-619-4777
Mailing Address - Fax:601-619-4667
Practice Address - Street 1:120 HOLT COLLIER DR
Practice Address - Street 2:SUITE D
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183-4408
Practice Address - Country:US
Practice Address - Phone:601-619-4777
Practice Address - Fax:601-619-4667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-20
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3153001223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02988820Medicaid