Provider Demographics
NPI:1356501696
Name:FOX, ETHAN (DDS)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:FOX
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1235 W VISTA WAY
Mailing Address - Street 2:SUITE K
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-6234
Mailing Address - Country:US
Mailing Address - Phone:760-631-0007
Mailing Address - Fax:760-631-0009
Practice Address - Street 1:1235 W VISTA WAY
Practice Address - Street 2:SUITE K
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-6234
Practice Address - Country:US
Practice Address - Phone:760-631-0007
Practice Address - Fax:760-631-0009
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52857122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist