=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366588501
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERVIN SIMMONS IV DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12528 LUSHER RD
-----------------------------------------------------
City | ST LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-741-4949
-----------------------------------------------------
Fax | 314-741-4958
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12528 LUSHER RD
-----------------------------------------------------
City | ST LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-741-4949
-----------------------------------------------------
Fax | 314-741-4958
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 13607
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------