Provider Demographics
NPI:1477203859
Name:WILCOX, ELIZABETH BROOKE
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:BROOKE
Last Name:WILCOX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16124 HOWARD LANDING DR
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20878-2262
Mailing Address - Country:US
Mailing Address - Phone:301-300-8151
Mailing Address - Fax:
Practice Address - Street 1:1060 W PARK LN STE 110
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:UT
Practice Address - Zip Code:84025-2994
Practice Address - Country:US
Practice Address - Phone:801-797-0069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-28
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13395841-9926122300000X
390200000X
UT13395841-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program