Healthcare Provider Details

I. General information

NPI: 1215084157
Provider Name (Legal Business Name): SIMON R. PRIOR DDS, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 05/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W 12TH AVE DENTAL FACULTY PRACTICE ASSOCIATION
COLUMBUS OH
43210-1267
US

IV. Provider business mailing address

305 W 12TH AVE 2148, POSTLE HALL
COLUMBUS OH
43210-1267
US

V. Phone/Fax

Practice location:
  • Phone: 614-247-0002
  • Fax:
Mailing address:
  • Phone: 614-247-8014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number0179
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number71-000179
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number71-000179
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: