Provider Demographics
NPI:1184064321
Name:SIMMONS, VAN ROBERT (DMD)
Entity type:Individual
Prefix:
First Name:VAN
Middle Name:ROBERT
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 CLARK AVE
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648-3968
Mailing Address - Country:US
Mailing Address - Phone:601-684-6532
Mailing Address - Fax:601-684-6431
Practice Address - Street 1:304 CLARK AVE
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-3968
Practice Address - Country:US
Practice Address - Phone:601-684-6532
Practice Address - Fax:601-684-6431
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-02
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1945-811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00064894Medicaid