Provider Demographics
NPI:1750435350
Name:FOULK ROAD DENTAL
Entity type:Organization
Organization Name:FOULK ROAD DENTAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:N
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:302-652-3775
Mailing Address - Street 1:1100 LOVERING AVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19806-3273
Mailing Address - Country:US
Mailing Address - Phone:302-652-7447
Mailing Address - Fax:
Practice Address - Street 1:300 FOULK RD
Practice Address - Street 2:SUITE 101
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19803-3886
Practice Address - Country:US
Practice Address - Phone:302-652-3775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEGI00010311223G0001X
DEGI000011571223G0001X
DEGI000011561223G0001X
DEGI00007191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty