MEDICARE: S.L. SIMMONS-BOYD, D.D.S., P.A.

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	6088	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	97795	OTHER	NC	BCBS PROVIDER NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	6088	OTHER	NC	NC STATE LICENSE

General Provider Information

NPI Number	:	1609045335
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	S.L. SIMMONS-BOYD, D.D.S., P.A.

Provider Business Mailing Address
First Line	:	725 PROVIDENCE RD
Second Line	:	SUITE 301
City	:	CHARLOTTE
State	:	NC
Zip	:	28207-2370
Country	:	US
Telephone Number	:	704-376-1696
Fax Number	:	704-376-1698

Provider Business Practice Location Address
First Line	:	725 PROVIDENCE RD
Second Line	:	SUITE 301
City	:	CHARLOTTE
State	:	NC
Zip	:	28207-2260
Country	:	US
Telephone Number	:	704-376-1696
Fax Number	:	704-376-1698

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. SANDRA SIMMONS-BOYD
Credential	:	D.D.S
Telephone Number	:	704-376-1696

Provider Enumeration Date	:	02/27/2008
Last Update Date	:	08/15/2008

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