Provider Demographics
NPI:1104838176
Name:SIMMONS, WILSON FREDERICK (DDS)
Entity Type:Individual
Prefix:DR
First Name:WILSON
Middle Name:FREDERICK
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:FRED
Other - Middle Name:
Other - Last Name:SIMMONS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:230 OAKWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103
Mailing Address - Country:US
Mailing Address - Phone:336-722-6662
Mailing Address - Fax:336-722-6666
Practice Address - Street 1:230 OAKWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103
Practice Address - Country:US
Practice Address - Phone:336-722-6662
Practice Address - Fax:336-722-6666
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC52391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8997826Medicaid
NC97826OtherBCBS