Healthcare Provider Details

I. General information

NPI: 1609974757
Provider Name (Legal Business Name): WILHELMINA FOUCHE O'REILLY D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514F E WOODROW WILSON AVE
JACKSON MS
39216-4538
US

IV. Provider business mailing address

514F E WOODROW WILSON AVE
JACKSON MS
39216-4538
US

V. Phone/Fax

Practice location:
  • Phone: 601-982-3132
  • Fax: 601-982-3136
Mailing address:
  • Phone: 601-982-3132
  • Fax: 601-982-3136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberPEDO-075-83
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: