Provider Demographics
NPI:1215044664
Name:FOX, CHARLES BRYAN (DMD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:BRYAN
Last Name:FOX
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11708 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40243-1426
Mailing Address - Country:US
Mailing Address - Phone:502-245-8627
Mailing Address - Fax:502-245-9395
Practice Address - Street 1:8711 OLD BARDSTOWN RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40291-4435
Practice Address - Country:US
Practice Address - Phone:502-231-4633
Practice Address - Fax:502-231-4722
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY77441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice