Provider Demographics
NPI:1730249442
Name:SIMON, DAVID R (DDS)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:R
Last Name:SIMON
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 1:523 ROUTE 306
Mailing Address - Street 2:
Mailing Address - City:SUFFERN
Mailing Address - State:NY
Mailing Address - Zip Code:10901
Mailing Address - Country:US
Mailing Address - Phone:845-362-5300
Mailing Address - Fax:845-362-5301
Practice Address - Street 1:523 ROUTE 306
Practice Address - Street 2:
Practice Address - City:SUFFERN
Practice Address - State:NY
Practice Address - Zip Code:10901-2111
Practice Address - Country:US
Practice Address - Phone:845-362-5300
Practice Address - Fax:845-362-5301
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2009-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048188122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02694131Medicaid