Provider Demographics
NPI:1720174709
Name:SIMON, ANTHONY MICHAEL (DMD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:MICHAEL
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 1:1700 E 12TH ST
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058
Mailing Address - Country:US
Mailing Address - Phone:541-298-4403
Mailing Address - Fax:541-298-4469
Practice Address - Street 1:1700 E 12TH ST
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058
Practice Address - Country:US
Practice Address - Phone:541-298-4403
Practice Address - Fax:541-298-4403
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD7248122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist