MEDICARE: DR. KELSEY WILCOX DMD

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	122300000X	Dentist	11842	CT

General Provider Information

NPI Number	:	1346761418
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELSEY WILCOX DMD

Provider Business Mailing Address
First Line	:	23 WAUREGAN RD
Second Line	:
City	:	BROOKLYN
State	:	CT
Zip	:	06234-1924
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	23 WAUREGAN RD
Second Line	:
City	:	BROOKLYN
State	:	CT
Zip	:	06234-1924
Country	:	US
Telephone Number	:	860-774-0876
Fax Number	:

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

Provider Enumeration Date	:	06/29/2017
Last Update Date	:	06/29/2017

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