Healthcare Provider Details

I. General information

NPI: 1912623141
Provider Name (Legal Business Name): WGO DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2022
Last Update Date: 10/19/2022
Certification Date: 10/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5858 RIDGEWOOD RD
JACKSON MS
39211-2617
US

IV. Provider business mailing address

5858 RIDGEWOOD RD
JACKSON MS
39211-2617
US

V. Phone/Fax

Practice location:
  • Phone: 601-594-9202
  • Fax:
Mailing address:
  • Phone: 601-594-9202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. CLORA EVANS
Title or Position: OWNER
Credential: DMD
Phone: 601-594-9202