Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | DS022175L | PA |
N | 1223P0700X | Prosthodontist | DS022175L | PA |
NPI | 1033539804 |
---|---|
Provider Name | Dr. David J. Fox |
First Address | Foxcroft Square, PA 19046-7024 |
Second Address | Philadelphia, PA 19130-3002 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/04/2014 |
Last Update Date | 21/02/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
DS-022175L | PENNSYLVANIA DEPARTMENT OF STATE - STATE BOARD OF DENTISTRY (01) | PA |