Provider Demographics
NPI:1457748154
Name:SIMON, KEITH (DMD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:
Last Name:SIMON
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 1:4340 W HILLSBOROUGH AVE STE 702
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-5560
Mailing Address - Country:US
Mailing Address - Phone:813-722-1050
Mailing Address - Fax:
Practice Address - Street 1:4340 W HILLSBOROUGH AVE STE 702
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-5560
Practice Address - Country:US
Practice Address - Phone:813-445-3240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-20
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN21658122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist