Provider Demographics
NPI:1821026600
Name:SIMON, MITCHELL JACK (DMD)
Entity type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:JACK
Last Name:SIMON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:MITCHELL
Other - Middle Name:J
Other - Last Name:SIMON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:960 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:11510-4241
Mailing Address - Country:US
Mailing Address - Phone:516-377-1818
Mailing Address - Fax:515-377-1831
Practice Address - Street 1:960 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:BALDWIN HARBOR
Practice Address - State:NY
Practice Address - Zip Code:11510-4241
Practice Address - Country:US
Practice Address - Phone:516-377-1818
Practice Address - Fax:515-377-1831
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0345261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice