MEDICARE: DR. GRANT RAYMOND WILLCOX DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	30043	CA

General Provider Information

NPI Number	:	1225160971
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GRANT RAYMOND WILLCOX DDS

Provider Business Mailing Address
First Line	:	200 S EL MOLINO AVE
Second Line	:	#3
City	:	PASADENA
State	:	CA
Zip	:	91101-2985
Country	:	US
Telephone Number	:	626-449-2996
Fax Number	:	626-449-3431

Provider Business Practice Location Address
First Line	:	200 S EL MOLINO AVE
Second Line	:	#3
City	:	PASADENA
State	:	CA
Zip	:	91101-2985
Country	:	US
Telephone Number	:	626-449-2996
Fax Number	:	626-449-3431

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2007
Last Update Date	:	07/08/2007

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