Provider Demographics
NPI:1023239068
Name:LLOYD B. WOLFE, JR., D.M.D.
Entity type:Organization
Organization Name:LLOYD B. WOLFE, JR., D.M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LLOYD
Authorized Official - Middle Name:B
Authorized Official - Last Name:WOLFE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-957-9200
Mailing Address - Street 1:406 BRIARWOOD DR STE 102
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-3059
Mailing Address - Country:US
Mailing Address - Phone:601-957-9200
Mailing Address - Fax:601-957-2060
Practice Address - Street 1:406 BRIARWOOD DR STE 102
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-3059
Practice Address - Country:US
Practice Address - Phone:601-957-9200
Practice Address - Fax:601-957-2060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2108841223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01589571Medicaid