Healthcare Provider Details

I. General information

NPI: 1275552176
Provider Name (Legal Business Name): JEFFREY LYNN WINGO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 JEFFERSON AVE
MEMPHIS TN
38104-2127
US

IV. Provider business mailing address

1030 JEFFERSON AVE
MEMPHIS TN
38104-2127
US

V. Phone/Fax

Practice location:
  • Phone: 901-523-8990
  • Fax: 901-577-7307
Mailing address:
  • Phone: 901-523-8990
  • Fax: 901-577-7307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number5235
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: