Healthcare Provider Details

I. General information

NPI: 1689472219
Provider Name (Legal Business Name): GIANCARLO AGNELLO SIMMONS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2025
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 ASYLUM AVE STE 3200
HARTFORD CT
06105-1702
US

IV. Provider business mailing address

83 WESTLAND AVE
WEST HARTFORD CT
06107-2731
US

V. Phone/Fax

Practice location:
  • Phone: 860-714-5782
  • Fax:
Mailing address:
  • Phone: 410-419-4540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2.014408
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: