MEDICARE: DR. GREGG OLIN WILCOX DMD

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	1223G0001X	General Practice Dentistry	6369	CT

General Provider Information

NPI Number	:	1558417576
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GREGG OLIN WILCOX DMD

Provider Business Mailing Address
First Line	:	23 WAUREGAN RD
Second Line	:
City	:	BROOKLYN
State	:	CT
Zip	:	06234-1924
Country	:	US
Telephone Number	:	860-774-0876
Fax Number	:	860-774-0886

Provider Business Practice Location Address
First Line	:	23 WAUREGAN RD
Second Line	:
City	:	BROOKLYN
State	:	CT
Zip	:	06234-1924
Country	:	US
Telephone Number	:	860-774-0876
Fax Number	:	860-774-0886

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

Provider Enumeration Date	:	01/25/2007
Last Update Date	:	07/08/2007

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