=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225360191
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PATRICK B. WILCOX D.D.S, PEDIATRIC DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2010
-----------------------------------------------------
Last Update Date | 02/03/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2501 CORNERSTONE BLVD
-----------------------------------------------------
City | EDINBURG
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78539-8463
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-686-8611
-----------------------------------------------------
Fax | 956-686-2668
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2501 CORNERSTONE BLVD
-----------------------------------------------------
City | EDINBURG
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78539-8463
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-686-8611
-----------------------------------------------------
Fax | 956-686-2668
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | D.D.S
-----------------------------------------------------
Name | DR. PATRICK B WILCOX
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 956-686-8611
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 15114
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------