Healthcare Provider Details

I. General information

NPI: 1205809282
Provider Name (Legal Business Name): CONSTANTINE SIMOS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 09/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 LIVINGSTON AVE
NEW BRUNSWICK NJ
08901-2410
US

IV. Provider business mailing address

109 LIVINGSTON AVE
NEW BRUNSWICK NJ
08901-2410
US

V. Phone/Fax

Practice location:
  • Phone: 732-247-8083
  • Fax: 732-247-1584
Mailing address:
  • Phone: 732-247-8083
  • Fax: 732-247-1584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDI 21508
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number047853
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: