Provider Demographics
NPI:1558417576
Name:WILCOX, GREGG OLIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:GREGG
Middle Name:OLIN
Last Name:WILCOX
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 1:23 WAUREGAN RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:CT
Mailing Address - Zip Code:06234-1924
Mailing Address - Country:US
Mailing Address - Phone:860-774-0876
Mailing Address - Fax:860-774-0886
Practice Address - Street 1:23 WAUREGAN RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:CT
Practice Address - Zip Code:06234-1924
Practice Address - Country:US
Practice Address - Phone:860-774-0876
Practice Address - Fax:860-774-0886
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT63691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice