Healthcare Provider Details

I. General information

NPI: 1891103321
Provider Name (Legal Business Name): MATTHEW E SIMON D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2014
Last Update Date: 03/25/2024
Certification Date: 03/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34800 BOB WILSON DR STE 200
SAN DIEGO CA
92134-2213
US

IV. Provider business mailing address

5925 LINDA VISTA RD APT 1008
SAN DIEGO CA
92110-7410
US

V. Phone/Fax

Practice location:
  • Phone: 619-556-8240
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8969
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code1223X2210X
TaxonomyOrofacial Pain Dentistry
License Number8969
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: