Healthcare Provider Details

I. General information

NPI: 1730421850
Provider Name (Legal Business Name): MICHELLE FOX, R.D.H.,S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2013
Last Update Date: 03/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9220 66TH ST
KENOSHA WI
53142-8234
US

IV. Provider business mailing address

9220 66TH STREET
KENOSHA WI
53142
US

V. Phone/Fax

Practice location:
  • Phone: 262-620-6997
  • Fax:
Mailing address:
  • Phone: 262-620-6997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number10253-16
License Number StateWI

VIII. Authorized Official

Name: MRS. MICHELLE FOX
Title or Position: REGISTERED DENTAL HYGIENIST
Credential: RDH
Phone: 262-620-6997