Provider Demographics
NPI:1720079023
Name:SIMMONS, RONNIE ROY (DDS)
Entity Type:Individual
Prefix:MR
First Name:RONNIE
Middle Name:ROY
Last Name:SIMMONS
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 1:924 S 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN BOW
Mailing Address - State:NE
Mailing Address - Zip Code:68822-3004
Mailing Address - Country:US
Mailing Address - Phone:308-872-6294
Mailing Address - Fax:308-872-6548
Practice Address - Street 1:924 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:BROKEN BOW
Practice Address - State:NE
Practice Address - Zip Code:68822-3004
Practice Address - Country:US
Practice Address - Phone:308-872-6294
Practice Address - Fax:308-872-6548
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE4119122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47059663800Medicaid