Provider Demographics
NPI:1720098510
Name:ROBERSON, RONAL (DMD)
Entity Type:Individual
Prefix:
First Name:RONAL
Middle Name:
Last Name:ROBERSON
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:PO BOX 337
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:MS
Mailing Address - Zip Code:38921-0337
Mailing Address - Country:US
Mailing Address - Phone:662-647-8442
Mailing Address - Fax:662-647-3559
Practice Address - Street 1:203 S MARKET ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:MS
Practice Address - Zip Code:38921-2236
Practice Address - Country:US
Practice Address - Phone:662-647-8442
Practice Address - Fax:662-647-3559
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1943-811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00064888Medicaid