MEDICARE: DR. CHARLES WILLIAM WILCOX D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0700X	Prosthodontics	4230	NE

General Provider Information

NPI Number	:	1558364349
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES WILLIAM WILCOX D.D.S.

Provider Business Mailing Address
First Line	:	1000 DEVON DR
Second Line	:
City	:	PAPILLION
State	:	NE
Zip	:	68046-3807
Country	:	US
Telephone Number	:	402-593-8136
Fax Number	:

Provider Business Practice Location Address
First Line	:	2500 CALIFORNIA PLZ
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68178-0001
Country	:	US
Telephone Number	:	402-280-5080
Fax Number	:	402-280-5094

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	07/08/2007

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