Provider Demographics
NPI:1578674271
Name:SIMONTON, FRED H III (DMD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:H
Last Name:SIMONTON
Suffix:III
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 SHERWOOD PARK DR NE STE C
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3404
Mailing Address - Country:US
Mailing Address - Phone:770-531-1075
Mailing Address - Fax:770-536-2815
Practice Address - Street 1:1221 SHERWOOD PARK DR NE STE C
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3404
Practice Address - Country:US
Practice Address - Phone:770-531-1075
Practice Address - Fax:770-536-2815
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0103671223S0112X
GA10367204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000344462AMedicaid