Provider Demographics
NPI:1154543296
Name:SIMONE, BRYAN J (DDS)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:J
Last Name:SIMONE
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 1:4178 HOOVER RD
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-3625
Mailing Address - Country:US
Mailing Address - Phone:614-875-3141
Mailing Address - Fax:614-875-8812
Practice Address - Street 1:4178 HOOVER RD
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123-3625
Practice Address - Country:US
Practice Address - Phone:614-875-3141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH19692122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0893636Medicaid