Provider Demographics
NPI:1689710030
Name:RED FOX, JOHN MICHAEL
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
Last Name:RED FOX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-6507
Mailing Address - Country:US
Mailing Address - Phone:903-753-2633
Mailing Address - Fax:
Practice Address - Street 1:410 N 3RD ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-6507
Practice Address - Country:US
Practice Address - Phone:903-753-2633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX146831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice