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NPI Code Detail

MEDICARE: DR. FREDDIE EARL WILKES JR. D.D.S.

MEDICARE: DR. FREDDIE EARL WILKES JR. D.D.S.
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
1122300000XDentistRES.3249OH
21223P0221XPediatric Dentistry4346-22MS

General Provider Information

NPI Number : 1972859627
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. FREDDIE EARL WILKES JR. D.D.S.
Provider Business Mailing Address
First Line : 3451 GOODMAN RD E STE 122
Second Line :
City : SOUTHAVEN
State : MS
Zip : 38672-9302
Country : US
Telephone Number : 662-892-8565
Fax Number :
Provider Business Practice Location Address
First Line : 2154 GOODMAN RD W # 1
Second Line :
City : HORN LAKE
State : MS
Zip : 38637-1303
Country : US
Telephone Number : 662-392-9200
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/31/2012
Last Update Date : 03/07/2023

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