MEDICARE: DR. MICHAEL R SIMON DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	45017	CA

General Provider Information

NPI Number	:	1003946203
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL R SIMON DDS

Provider Business Mailing Address
First Line	:	36 MALAGA COVE PLZ
Second Line	:	SUITE #310
City	:	PALOS VERDES ESTATES
State	:	CA
Zip	:	90274-6811
Country	:	US
Telephone Number	:	310-375-8888
Fax Number	:	310-375-7883

Provider Business Practice Location Address
First Line	:	36 MALAGA COVE PLZ
Second Line	:	SUITE #310
City	:	PALOS VERDES ESTATES
State	:	CA
Zip	:	90274-6811
Country	:	US
Telephone Number	:	310-375-8888
Fax Number	:	310-375-7883

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/06/2007
Last Update Date	:	07/08/2007

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