Provider Demographics
NPI:1841578408
Name:FOX, MARISA S (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARISA
Middle Name:S
Last Name:FOX
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:MARISA
Other - Middle Name:S
Other - Last Name:SONERHOLM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:4700 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97603-4959
Mailing Address - Country:US
Mailing Address - Phone:541-273-6100
Mailing Address - Fax:541-273-6107
Practice Address - Street 1:4700 S 6TH ST
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97603-4959
Practice Address - Country:US
Practice Address - Phone:541-273-6100
Practice Address - Fax:541-273-6107
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-01
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9618122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist