Provider Demographics
NPI:1225072283
Name:SIMON, K. MARTIN (DDS)
Entity Type:Individual
Prefix:
First Name:K.
Middle Name:MARTIN
Last Name:SIMON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:391 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05663-5745
Mailing Address - Country:US
Mailing Address - Phone:802-485-3051
Mailing Address - Fax:802-485-8384
Practice Address - Street 1:391 S MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:VT
Practice Address - Zip Code:05663-5745
Practice Address - Country:US
Practice Address - Phone:802-485-3051
Practice Address - Fax:802-485-8384
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT7851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0002415Medicaid