Provider Demographics
NPI:1992900021
Name:SIM, AUDREY (DDS)
Entity type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:
Last Name:SIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2413 W ALGONQUIN RD # 514
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-9402
Mailing Address - Country:US
Mailing Address - Phone:847-648-2739
Mailing Address - Fax:877-563-8052
Practice Address - Street 1:785 S RANDALL RD
Practice Address - Street 2:
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102-5914
Practice Address - Country:US
Practice Address - Phone:847-648-2739
Practice Address - Fax:877-563-8052
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-19
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190233241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice