Provider Demographics
NPI:1356663025
Name:FRED H SIMMONS JR
Entity Type:Organization
Organization Name:FRED H SIMMONS JR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:H
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS,MSD
Authorized Official - Phone:812-232-1138
Mailing Address - Street 1:3404 S 7TH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-4017
Mailing Address - Country:US
Mailing Address - Phone:812-232-1138
Mailing Address - Fax:
Practice Address - Street 1:3404 S 7TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-4017
Practice Address - Country:US
Practice Address - Phone:812-232-1138
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-23
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120069841223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100250180AMedicaid