Provider Demographics
NPI:1841202835
Name:SIMMONS-BOYD, SANDRA L (DDS)
Entity type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:L
Last Name:SIMMONS-BOYD
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 1:2304 ARDEN GATE LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-4482
Mailing Address - Country:US
Mailing Address - Phone:704-503-4256
Mailing Address - Fax:
Practice Address - Street 1:725 PROVIDENCE RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-2370
Practice Address - Country:US
Practice Address - Phone:704-376-1696
Practice Address - Fax:704-376-1698
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC60881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8997795Medicaid
NC01-27-972OtherSTATE EMPLOYEE ID
NCBCBS97795OtherBLUE CROSS BLUE SHIELD PR