Provider Demographics
NPI:1275586950
Name:SIMMONS, JEFFREY JAMES (DMD MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:JAMES
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:DMD MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 ENTERPRISE BLVD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-6301
Mailing Address - Country:US
Mailing Address - Phone:864-234-8811
Mailing Address - Fax:864-234-8844
Practice Address - Street 1:10 ENTERPRISE BLVD
Practice Address - Street 2:SUITE 209
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-6301
Practice Address - Country:US
Practice Address - Phone:864-234-8811
Practice Address - Fax:864-234-8844
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC41501223P0106X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX4150Medicaid
SC2015Medicare PIN
SCZX4150Medicaid