Provider Demographics
NPI:1457498016
Name:WILCOX, LESLIE LORRAINE (DDS)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:LORRAINE
Last Name:WILCOX
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16342 COUNTY ROAD 30
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-1207
Mailing Address - Country:US
Mailing Address - Phone:763-420-9876
Mailing Address - Fax:
Practice Address - Street 1:16342 COUNTY ROAD 30
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55311-1207
Practice Address - Country:US
Practice Address - Phone:763-420-9876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN95901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice