Provider Demographics
NPI:1306867767
Name:SIMON, JEREMY STEPHEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:STEPHEN
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:PO BOX 150
Mailing Address - Street 2:
Mailing Address - City:ALMA
Mailing Address - State:AR
Mailing Address - Zip Code:72921
Mailing Address - Country:US
Mailing Address - Phone:479-430-7049
Mailing Address - Fax:479-430-7051
Practice Address - Street 1:191 HWY 64 EAST
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:AR
Practice Address - Zip Code:72921
Practice Address - Country:US
Practice Address - Phone:479-430-7049
Practice Address - Fax:479-430-7051
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR34401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5X479OtherBLUE CROSS BLUE SHIELD