Healthcare Provider Details

I. General information

NPI: 1912004730
Provider Name (Legal Business Name): SIMMONS DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 02/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1029 ELIZABETH LAKE RD
PALMDALE CA
93551
US

IV. Provider business mailing address

1029 ELIZABETH LAKE RD
PALMDALE CA
93551
US

V. Phone/Fax

Practice location:
  • Phone: 661-947-3163
  • Fax: 661-947-0538
Mailing address:
  • Phone: 661-947-3163
  • Fax: 661-947-0538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number31979
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number29916
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number24629
License Number StateCA

VIII. Authorized Official

Name: DR. GERALD SCOTT SIMMONS
Title or Position: OWNER
Credential: DR
Phone: 661-947-3163