=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174920110
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHRISTY KENNA FOX, DDS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2014
-----------------------------------------------------
Last Update Date | 11/19/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 606 STOKES DR SUITE B
-----------------------------------------------------
City | HINTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25951-2554
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-466-4700
-----------------------------------------------------
Fax | 304-466-4848
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | RR 1 BOX 301F
-----------------------------------------------------
City | HINTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25951-9744
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-466-3223
-----------------------------------------------------
Fax | 304-466-4848
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. CHRISTY KENNA FOX
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 304-466-4700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 3333
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------