MEDICARE: DR. DWIGHT SIMMONS DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	019025863	IL

General Provider Information

NPI Number	:	1184638207
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DWIGHT SIMMONS DDS

Provider Business Mailing Address
First Line	:	19445 W FOREST LN
Second Line	:
City	:	MUNDELEIN
State	:	IL
Zip	:	60060-3496
Country	:	US
Telephone Number	:	847-393-7100
Fax Number	:

Provider Business Practice Location Address
First Line	:	27620 75TH ST
Second Line	:	SUITE 3
City	:	SALEM
State	:	WI
Zip	:	53168-9530
Country	:	US
Telephone Number	:	262-843-1808
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/27/2006
Last Update Date	:	04/24/2012

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