Provider Demographics
NPI:1336347517
Name:SIMEONOVA, LIDIA SIMEONOVA (DDS)
Entity Type:Individual
Prefix:
First Name:LIDIA
Middle Name:SIMEONOVA
Last Name:SIMEONOVA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 76TH ST
Mailing Address - Street 2:APT 1
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047-5503
Mailing Address - Country:US
Mailing Address - Phone:201-936-7300
Mailing Address - Fax:212-995-4843
Practice Address - Street 1:409 76TH ST
Practice Address - Street 2:APT 1
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-5503
Practice Address - Country:US
Practice Address - Phone:201-936-7300
Practice Address - Fax:212-995-4843
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI022918001223G0001X
NJ22DI022918011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice