Provider Demographics
NPI:1649384942
Name:SIMON, MARVIN VICTOR (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:VICTOR
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 1:11885 HOLLY LANE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20601
Mailing Address - Country:US
Mailing Address - Phone:301-843-7020
Mailing Address - Fax:
Practice Address - Street 1:11885 HOLLY LANE
Practice Address - Street 2:SUITE 3
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20601
Practice Address - Country:US
Practice Address - Phone:301-843-7020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD3717122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist