Healthcare Provider Details

I. General information

NPI: 1023239068
Provider Name (Legal Business Name): LLOYD B. WOLFE, JR., D.M.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 06/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 BRIARWOOD DR STE 102
JACKSON MS
39206-3059
US

IV. Provider business mailing address

406 BRIARWOOD DR STE 102
JACKSON MS
39206-3059
US

V. Phone/Fax

Practice location:
  • Phone: 601-957-9200
  • Fax: 601-957-2060
Mailing address:
  • Phone: 601-957-9200
  • Fax: 601-957-2060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number210884
License Number StateMS

VIII. Authorized Official

Name: DR. LLOYD B. WOLFE JR.
Title or Position: ORTHODONTIST
Credential: D.M.D.
Phone: 601-957-9200