Healthcare Provider Details

I. General information

NPI: 1629034277
Provider Name (Legal Business Name): RONNY MICHAEL SIMMONS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12TH ADS/SGGD 221 3RD STREET WEST, BLDG 1040
RANDOLPH AFB TX
78150-4801
US

IV. Provider business mailing address

3139 RUSTIC OAK
SAN ANTONIO TX
78261-2211
US

V. Phone/Fax

Practice location:
  • Phone: 210-652-1846
  • Fax: 210-652-1368
Mailing address:
  • Phone: 830-980-4949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3204
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: