Provider Demographics
NPI:1831366707
Name:BRYAN J. SIMONE D.D.S.,LLC
Entity type:Organization
Organization Name:BRYAN J. SIMONE D.D.S.,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:SIMONE
Authorized Official - Suffix:
Authorized Official - Credentials:DSS
Authorized Official - Phone:614-875-3141
Mailing Address - Street 1:4104 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-3065
Mailing Address - Country:US
Mailing Address - Phone:614-875-3141
Mailing Address - Fax:614-875-8812
Practice Address - Street 1:4104 BROADWAY
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123-3065
Practice Address - Country:US
Practice Address - Phone:614-875-3141
Practice Address - Fax:614-875-8812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-10
Last Update Date:2008-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-19692122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2798012Medicaid