Provider Demographics
NPI:1033221098
Name:DR LARRY DEAN SIMMONS DDS PA
Entity Type:Organization
Organization Name:DR LARRY DEAN SIMMONS DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:336-789-2075
Mailing Address - Street 1:1007 ROCKFORD ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MOUNT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-5325
Mailing Address - Country:US
Mailing Address - Phone:336-789-2075
Mailing Address - Fax:336-789-2041
Practice Address - Street 1:1007 ROCKFORD ST
Practice Address - Street 2:SUITE 1
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-5325
Practice Address - Country:US
Practice Address - Phone:336-789-2075
Practice Address - Fax:336-789-2041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4115122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8997831Medicaid