Healthcare Provider Details

I. General information

NPI: 1497089197
Provider Name (Legal Business Name): SHENEKIA AYANA WELLS WIGGINS D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2009
Last Update Date: 09/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3502 W NORTHSIDE DR
JACKSON MS
39213-4454
US

IV. Provider business mailing address

5207 MEADOW OAKS PARK DR
JACKSON MS
39211-4820
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-5321
  • Fax:
Mailing address:
  • Phone: 769-216-2913
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3527-09
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: