Healthcare Provider Details

I. General information

NPI: 1285565366
Provider Name (Legal Business Name): WESLIE ANN BLACKLEDGE DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

97 HAL CROCKER RD
ELLISVILLE MS
39437-2088
US

IV. Provider business mailing address

16 PARKER RDG
PETAL MS
39465-9274
US

V. Phone/Fax

Practice location:
  • Phone: 601-477-3779
  • Fax:
Mailing address:
  • Phone: 601-480-3531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number112663
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: