Provider Demographics
NPI:1174097695
Name:WILCOX, STACY LYNN (RDH, LAP)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:LYNN
Last Name:WILCOX
Suffix:
Gender:F
Credentials:RDH, LAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 WATER LINE RD
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-7024
Mailing Address - Country:US
Mailing Address - Phone:406-490-7392
Mailing Address - Fax:406-496-6035
Practice Address - Street 1:445 CENTENNIAL AVE
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-2870
Practice Address - Country:US
Practice Address - Phone:406-496-6000
Practice Address - Fax:406-496-6035
Is Sole Proprietor?:No
Enumeration Date:2019-01-17
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT5999124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist