=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275147787
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TROY SIMMONS, DDS, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2020
-----------------------------------------------------
Last Update Date | 09/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3801 NORTH ST STE 5
-----------------------------------------------------
City | NACOGDOCHES
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75965-2475
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-560-2275
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3801 NORTH ST STE 5
-----------------------------------------------------
City | NACOGDOCHES
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75965-2475
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-560-2275
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TROY SIMMONS
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 936-560-2275
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------