MEDICARE: WIGGINS FAMILY DENTAL, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	387116	MS

General Provider Information

NPI Number	:	1518487230
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WIGGINS FAMILY DENTAL, PLLC

Provider Business Mailing Address
First Line	:	203 S MARKET ST
Second Line	:
City	:	CHARLESTON
State	:	MS
Zip	:	38921-2236
Country	:	US
Telephone Number	:	662-647-8442
Fax Number	:	662-647-3559

Provider Business Practice Location Address
First Line	:	203 S MARKET ST
Second Line	:
City	:	CHARLESTON
State	:	MS
Zip	:	38921-2236
Country	:	US
Telephone Number	:	662-647-8442
Fax Number	:	662-647-3559

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	KYLE R WIGGINS
Credential	:	DMD
Telephone Number	:	662-647-8442

Provider Enumeration Date	:	06/23/2017
Last Update Date	:	07/21/2022

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