Provider Demographics
NPI:1154691434
Name:WARDLAW, JIMMY LEE SR
Entity type:Individual
Prefix:DR
First Name:JIMMY
Middle Name:LEE
Last Name:WARDLAW
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 SCENIC DR
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75032-8615
Mailing Address - Country:US
Mailing Address - Phone:972-771-8602
Mailing Address - Fax:972-771-8602
Practice Address - Street 1:107 SCENIC DR
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032-8615
Practice Address - Country:US
Practice Address - Phone:972-771-8602
Practice Address - Fax:972-771-8602
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-04
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8100122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist