Provider Demographics
NPI:1134147119
Name:SIMON, ROBERT LAWRENCE (DDS)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LAWRENCE
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 1:1321 N HARBOR BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-4130
Mailing Address - Country:US
Mailing Address - Phone:714-525-5200
Mailing Address - Fax:714-525-5998
Practice Address - Street 1:1321 N HARBOR BLVD STE 203
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-4130
Practice Address - Country:US
Practice Address - Phone:714-525-5200
Practice Address - Fax:714-525-5998
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA241801223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA24180OtherDENTAL LICENSE