Healthcare Provider Details

I. General information

NPI: 1275389363
Provider Name (Legal Business Name): JESSYCA ALEXIS WOFFORD DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2024
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 PAVILION PKWY STE 15
FAYETTEVILLE GA
30214-7732
US

IV. Provider business mailing address

117 PAVILION PKWY STE 15
FAYETTEVILLE GA
30214-7732
US

V. Phone/Fax

Practice location:
  • Phone: 770-953-6975
  • Fax:
Mailing address:
  • Phone: 770-953-6975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN124278
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: