Provider Demographics
NPI:1851038384
Name:SIMMONS, TAVIAN (DDS)
Entity Type:Individual
Prefix:
First Name:TAVIAN
Middle Name:
Last Name:SIMMONS
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 1:6729 STANHOPE DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254
Mailing Address - Country:US
Mailing Address - Phone:252-642-4822
Mailing Address - Fax:
Practice Address - Street 1:550 N. UNIVERSITY BLVD STE. 3195
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-0001
Practice Address - Country:US
Practice Address - Phone:317-274-5315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-16
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC127361223G0001X
IN12014152A1223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program