Provider Demographics
NPI:1609045335
Name:S.L. SIMMONS-BOYD, D.D.S., P.A.
Entity Type:Organization
Organization Name:S.L. SIMMONS-BOYD, D.D.S., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMMONS-BOYD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:704-376-1696
Mailing Address - Street 1:725 PROVIDENCE RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-2370
Mailing Address - Country:US
Mailing Address - Phone:704-376-1696
Mailing Address - Fax:704-376-1698
Practice Address - Street 1:725 PROVIDENCE RD
Practice Address - Street 2:SUITE 301
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-2260
Practice Address - Country:US
Practice Address - Phone:704-376-1696
Practice Address - Fax:704-376-1698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-27
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC60881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC97795OtherBCBS PROVIDER NUMBER
NC8997795Medicaid
NC6088OtherNC STATE LICENSE
NC6088OtherNC STATE LICENSE