Provider Demographics
NPI:1124164421
Name:SIMMONS, MARTIN JOHN (DDS)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:JOHN
Last Name:SIMMONS
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 1:3380 OLD JEFFERSON RD
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30607-1480
Mailing Address - Country:US
Mailing Address - Phone:706-548-3279
Mailing Address - Fax:706-546-6475
Practice Address - Street 1:3380 OLD JEFFERSON ROAD
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30607
Practice Address - Country:US
Practice Address - Phone:706-548-3279
Practice Address - Fax:706-546-6475
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN006805122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00346585AMedicaid