Provider Demographics
NPI:1952930778
Name:SIMMONS, ANGEL A
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:A
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5125 DELTA ST
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-6350
Mailing Address - Country:US
Mailing Address - Phone:843-343-9991
Mailing Address - Fax:
Practice Address - Street 1:11503 SUNRISE VALLEY DR
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-1505
Practice Address - Country:US
Practice Address - Phone:703-860-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-03
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3999124Q00000X
GADH12296124Q00000X
VA0402207342124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist