Provider Demographics
NPI:1811086341
Name:WILCOX, V BRUCE (DMD)
Entity type:Individual
Prefix:
First Name:V
Middle Name:BRUCE
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:PO BOX 3630
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86003-3630
Mailing Address - Country:US
Mailing Address - Phone:928-522-9400
Mailing Address - Fax:928-774-4808
Practice Address - Street 1:2920 N 4TH ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-1816
Practice Address - Country:US
Practice Address - Phone:928-522-9405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000098921223G0001X
AZD0104871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA296060OtherL&I
WA5046289Medicaid
WA5046289OtherCHPW
WA5046289Medicaid