Provider Demographics
NPI:1609955251
Name:VAN R SIMMONS DMD PA
Entity Type:Organization
Organization Name:VAN R SIMMONS DMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:VAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-684-6532
Mailing Address - Street 1:PO BOX 885
Mailing Address - Street 2:304 CLARKE AVE
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648
Mailing Address - Country:US
Mailing Address - Phone:601-684-6532
Mailing Address - Fax:601-684-6431
Practice Address - Street 1:304 CLARKE AVE
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648
Practice Address - Country:US
Practice Address - Phone:601-684-6532
Practice Address - Fax:601-684-6431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1945811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00064894Medicaid