Provider Demographics
NPI:1497843411
Name:WILLCOX, BLAIR AUSTIN (DMD)
Entity Type:Individual
Prefix:
First Name:BLAIR
Middle Name:AUSTIN
Last Name:WILLCOX
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2138 N ALAMO CIR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-2265
Mailing Address - Country:US
Mailing Address - Phone:480-580-7222
Mailing Address - Fax:
Practice Address - Street 1:19555 N 59TH AVE - CDMI
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308
Practice Address - Country:US
Practice Address - Phone:480-580-7222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZD4391122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist