Healthcare Provider Details

I. General information

NPI: 1629229547
Provider Name (Legal Business Name): JIMMY A. WOFFORD D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2008
Last Update Date: 10/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 N. MAIN ST.
FT. STOCKTON TX
79735
US

IV. Provider business mailing address

PO BOX 1016
FT. STOCKTON TX
79735
US

V. Phone/Fax

Practice location:
  • Phone: 432-336-5522
  • Fax: 432-336-5523
Mailing address:
  • Phone: 432-336-5522
  • Fax: 432-336-5523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number10759
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: