Healthcare Provider Details

I. General information

NPI: 1366474272
Provider Name (Legal Business Name): GERARD LOUIS SIMONEAUX D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7939 HONEYGO BLVD SUITE 227
BALTIMORE MD
21236-4931
US

IV. Provider business mailing address

619 YARMOUTH RD
BALTIMORE MD
21286-7838
US

V. Phone/Fax

Practice location:
  • Phone: 410-931-0250
  • Fax: 410-931-4876
Mailing address:
  • Phone: 410-377-5870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number13445
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: