Healthcare Provider Details

I. General information

NPI: 1649720079
Provider Name (Legal Business Name): YAHAZIEL SIMON D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2016
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4763 ATLANTA HWY STE 380
LOGANVILLE GA
30052-6793
US

IV. Provider business mailing address

PO BOX 952
FOREST PARK GA
30298-0952
US

V. Phone/Fax

Practice location:
  • Phone: 770-962-9560
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN015206
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN015206
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: