Provider Demographics
NPI:1134216443
Name:FOX, THOMAS CARL (DMD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:CARL
Last Name:FOX
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11076 STATE HIGHWAY 18
Mailing Address - Street 2:
Mailing Address - City:CONNEAUT LAKE
Mailing Address - State:PA
Mailing Address - Zip Code:16316-3530
Mailing Address - Country:US
Mailing Address - Phone:814-382-2945
Mailing Address - Fax:
Practice Address - Street 1:11076 STATE HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:CONNEAUT LAKE
Practice Address - State:PA
Practice Address - Zip Code:16316-3530
Practice Address - Country:US
Practice Address - Phone:814-382-2945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS024056L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA186327OtherUNITED CONCORDIA ID
PA1013460Medicaid