Provider Demographics
NPI:1215090675
Name:SIMON, MICHAEL A (DMD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:SIMON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 E HALLANDALE BEACH BLVD
Mailing Address - Street 2:SUITE 700
Mailing Address - City:HALLANDALE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33009-4834
Mailing Address - Country:US
Mailing Address - Phone:954-456-5400
Mailing Address - Fax:954-456-8278
Practice Address - Street 1:2500 E HALLANDALE BEACH BLVD
Practice Address - Street 2:SUITE 700
Practice Address - City:HALLANDALE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33009-4834
Practice Address - Country:US
Practice Address - Phone:954-456-5400
Practice Address - Fax:954-456-8278
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL122071223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU41750Medicare UPIN
FL69341ZMedicare ID - Type UnspecifiedPROVIDER NUMBER