Provider Demographics
NPI:1114166204
Name:ROY, SIMON
Entity Type:Individual
Prefix:
First Name:SIMON
Middle Name:
Last Name:ROY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 GREENWOOD TER APT C5
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:VT
Mailing Address - Zip Code:05602-2827
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:31 MOUNTAIN VIEW DRIVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VT
Practice Address - Zip Code:05828
Practice Address - Country:US
Practice Address - Phone:802-684-1133
Practice Address - Fax:802-684-1138
Is Sole Proprietor?:No
Enumeration Date:2009-02-12
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT016-0002243122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist