Provider Demographics
NPI:1922044072
Name:SIMMONS, RAYMOND LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:LEE
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 1:523 8TH ST S
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-3503
Mailing Address - Country:US
Mailing Address - Phone:218-236-9319
Mailing Address - Fax:218-236-9319
Practice Address - Street 1:523 8TH ST S
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-3503
Practice Address - Country:US
Practice Address - Phone:218-236-9319
Practice Address - Fax:218-236-9319
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7603122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN61376SIOtherBLUE CROSS FEP
ND989045OtherDSCND
ND40617OtherND MEDICAL ASSISTANCE