Provider Demographics
NPI:1417530411
Name:FOX, SKY LEE
Entity Type:Individual
Prefix:
First Name:SKY
Middle Name:LEE
Last Name:FOX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8910 N REGENT RD
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-1750
Mailing Address - Country:US
Mailing Address - Phone:414-350-7257
Mailing Address - Fax:
Practice Address - Street 1:8910 N REGENT RD
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:WI
Practice Address - Zip Code:53217-1750
Practice Address - Country:US
Practice Address - Phone:414-350-7257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-28
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI1002634-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program