Healthcare Provider Details

I. General information

NPI: 1205753217
Provider Name (Legal Business Name): BLAKE WILCOX DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2026
Last Update Date: 07/01/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 E LAKE MEAD BLVD
NORTH LAS VEGAS NV
89030-6464
US

IV. Provider business mailing address

3345 SOLENTO LN
HENDERSON NV
89044-1735
US

V. Phone/Fax

Practice location:
  • Phone: 702-649-2789
  • Fax:
Mailing address:
  • Phone: 702-860-8781
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8416
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: