MEDICARE: RONAL ROBERSON DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	1943-81	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720098510
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RONAL ROBERSON DMD

Provider Business Mailing Address
First Line	:	PO BOX 337
Second Line	:
City	:	CHARLESTON
State	:	MS
Zip	:	38921-0337
Country	:	US
Telephone Number	:	662-647-8442
Fax Number	:	662-647-3559

Provider Business Practice Location Address
First Line	:	203 S MARKET ST
Second Line	:
City	:	CHARLESTON
State	:	MS
Zip	:	38921-2236
Country	:	US
Telephone Number	:	662-647-8442
Fax Number	:	662-647-3559

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/08/2006
Last Update Date	:	07/08/2007

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