Provider Demographics
NPI:1245036383
Name:SIMMONS, NATHANIAL DAVID
Entity type:Individual
Prefix:
First Name:NATHANIAL
Middle Name:DAVID
Last Name:SIMMONS
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 1:5974 HOLSTEIN DR
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CO
Mailing Address - Zip Code:80528-9135
Mailing Address - Country:US
Mailing Address - Phone:208-841-8871
Mailing Address - Fax:
Practice Address - Street 1:1001 CENTRE AVE
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-6047
Practice Address - Country:US
Practice Address - Phone:970-407-1001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-20
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.00206338122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty