Provider Demographics
NPI:1669560405
Name:WRIGHT, ROGER ALAN (D M D)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:ALAN
Last Name:WRIGHT
Suffix:
Gender:M
Credentials:D M D
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 212
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:MS
Mailing Address - Zip Code:39730-0212
Mailing Address - Country:US
Mailing Address - Phone:662-369-2063
Mailing Address - Fax:662-369-2076
Practice Address - Street 1:513 W COMMERCE ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:MS
Practice Address - Zip Code:39730-2543
Practice Address - Country:US
Practice Address - Phone:662-369-2063
Practice Address - Fax:662-369-2076
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1860-79122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00064708Medicaid