Provider Demographics
NPI:1366535338
Name:WOODS, ROGER DOUGLAS (DMD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:DOUGLAS
Last Name:WOODS
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 1:620 E THIRD ST
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:MS
Mailing Address - Zip Code:39074-4226
Mailing Address - Country:US
Mailing Address - Phone:601-469-2664
Mailing Address - Fax:601-469-2955
Practice Address - Street 1:620 E THIRD ST
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:MS
Practice Address - Zip Code:39074-4226
Practice Address - Country:US
Practice Address - Phone:601-469-2664
Practice Address - Fax:601-469-2955
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1859791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice