Provider Demographics
NPI:1003946203
Name:SIMON, MICHAEL R (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
Last Name:SIMON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:36 MALAGA COVE PLZ
Mailing Address - Street 2:SUITE #310
Mailing Address - City:PALOS VERDES ESTATES
Mailing Address - State:CA
Mailing Address - Zip Code:90274-6811
Mailing Address - Country:US
Mailing Address - Phone:310-375-8888
Mailing Address - Fax:310-375-7883
Practice Address - Street 1:36 MALAGA COVE PLZ
Practice Address - Street 2:SUITE #310
Practice Address - City:PALOS VERDES ESTATES
Practice Address - State:CA
Practice Address - Zip Code:90274-6811
Practice Address - Country:US
Practice Address - Phone:310-375-8888
Practice Address - Fax:310-375-7883
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA450171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice