Healthcare Provider Details

I. General information

NPI: 1568103786
Provider Name (Legal Business Name): FAITH SIMIYU DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2022
Last Update Date: 09/16/2022
Certification Date: 09/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4510 EDMONDSON AVE
BALTIMORE MD
21229-1506
US

IV. Provider business mailing address

407 N 40TH ST
PHILADELPHIA PA
19104-4682
US

V. Phone/Fax

Practice location:
  • Phone: 410-233-5777
  • Fax:
Mailing address:
  • Phone: 615-927-5456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number17556
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: