Provider Demographics
NPI:1134102999
Name:WILLCOX, BRYCE RUSTIN (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:BRYCE
Middle Name:RUSTIN
Last Name:WILLCOX
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11545 SW DURHAM RD
Mailing Address - Street 2:SUITE B-6
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-3473
Mailing Address - Country:US
Mailing Address - Phone:503-620-4626
Mailing Address - Fax:503-601-6004
Practice Address - Street 1:11545 SW DURHAM RD
Practice Address - Street 2:SUITE B-6
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-3473
Practice Address - Country:US
Practice Address - Phone:503-620-4626
Practice Address - Fax:503-601-6004
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD81111223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics