Provider Demographics
NPI:1891253068
Name:SIMON, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:SIMON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176 STONE SCHOOLHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGBURG
Mailing Address - State:NY
Mailing Address - Zip Code:12721-3001
Mailing Address - Country:US
Mailing Address - Phone:845-733-4400
Mailing Address - Fax:
Practice Address - Street 1:SOUTH DRIVE SCHOOL OF DENTAL MEDICINE
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-0001
Practice Address - Country:US
Practice Address - Phone:631-632-3161
Practice Address - Fax:631-632-3961
Is Sole Proprietor?:No
Enumeration Date:2019-03-06
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program