Provider Demographics
NPI:1699068411
Name:BRANDON R. WILCOX, D.D.S., P.C.
Entity type:Organization
Organization Name:BRANDON R. WILCOX, D.D.S., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:RODNEY
Authorized Official - Last Name:WILCOX
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:308-762-6131
Mailing Address - Street 1:916 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:ALLIANCE
Mailing Address - State:NE
Mailing Address - Zip Code:69301-2858
Mailing Address - Country:US
Mailing Address - Phone:308-762-6131
Mailing Address - Fax:308-762-6132
Practice Address - Street 1:916 W 10TH ST
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:NE
Practice Address - Zip Code:69301-2858
Practice Address - Country:US
Practice Address - Phone:308-762-6131
Practice Address - Fax:308-762-6132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-26
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE69261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE100259327-00Medicaid