Provider Demographics
NPI:1598939183
Name:FOX PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:FOX PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:ETHAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:858-248-3359
Mailing Address - Street 1:1235 W VISTA WAY STE K
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083
Mailing Address - Country:US
Mailing Address - Phone:760-631-0007
Mailing Address - Fax:760-631-0009
Practice Address - Street 1:1235 W VISTA WAY STE K
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083
Practice Address - Country:US
Practice Address - Phone:760-631-0007
Practice Address - Fax:760-631-0009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52857122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty