Healthcare Provider Details

I. General information

NPI: 1962037689
Provider Name (Legal Business Name): DR. NICHOLAS SIMON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2020
Last Update Date: 03/03/2026
Certification Date: 03/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 W FOOTHILL BLVD
GLENDORA CA
91741-3358
US

IV. Provider business mailing address

310 W FOOTHILL BLVD
GLENDORA CA
91741-3358
US

V. Phone/Fax

Practice location:
  • Phone: 626-335-1208
  • Fax:
Mailing address:
  • Phone: 626-335-1208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number109281
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: