Healthcare Provider Details

I. General information

NPI: 1558364349
Provider Name (Legal Business Name): CHARLES WILLIAM WILCOX D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 CALIFORNIA PLZ
OMAHA NE
68178-0001
US

IV. Provider business mailing address

1000 DEVON DR
PAPILLION NE
68046-3807
US

V. Phone/Fax

Practice location:
  • Phone: 402-280-5080
  • Fax: 402-280-5094
Mailing address:
  • Phone: 402-593-8136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number4230
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: