Healthcare Provider Details

I. General information

NPI: 1134349160
Provider Name (Legal Business Name): LLOYD B. WOLFE JR. D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 08/06/2012
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:
Title or Position:
Credential:
Phone: