Provider Demographics
NPI:1396952057
Name:COLOM, ROLAND FRANKLIN (DDS)
Entity type:Individual
Prefix:
First Name:ROLAND
Middle Name:FRANKLIN
Last Name:COLOM
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 1:907 MILITARY RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39701
Mailing Address - Country:US
Mailing Address - Phone:662-328-1252
Mailing Address - Fax:662-329-3165
Practice Address - Street 1:907 MILITARY RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39701
Practice Address - Country:US
Practice Address - Phone:662-328-1252
Practice Address - Fax:662-329-3165
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1883 80122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00064765Medicaid