Healthcare Provider Details

I. General information

NPI: 1770564148
Provider Name (Legal Business Name): DENNIS M WILCOX MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 12/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3904 W 125TH TERRACE
LEAWOOD KS
66209-2643
US

IV. Provider business mailing address

23625 COMMERCE PARK SUITE 204
BEACHWOOD OH
44122
US

V. Phone/Fax

Practice location:
  • Phone: 216-255-5700
  • Fax: 216-255-5701
Mailing address:
  • Phone: 216-255-5701
  • Fax: 216-255-5701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number28051
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: