Healthcare Provider Details

I. General information

NPI: 1073849808
Provider Name (Legal Business Name): MICHAEL A. WILCOX D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2009
Last Update Date: 10/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7170 HWY 49
LOTUS CA
95651-0944
US

IV. Provider business mailing address

P.O. BOX 944 COLOMA DENTAL OFFICE
LOTUS CA
95651-0944
US

V. Phone/Fax

Practice location:
  • Phone: 530-621-0900
  • Fax: 530-621-0903
Mailing address:
  • Phone: 530-621-0900
  • Fax: 530-621-0903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number25050
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: