MEDICARE: DR. RACHAEL LARA SIMON 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	1223P0221X	Pediatric Dentistry	12414	MD

General Provider Information

NPI Number	:	1417076191
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RACHAEL LARA SIMON DDS

Provider Business Mailing Address
First Line	:	11862 RAMSBURG RD
Second Line	:
City	:	MARRIOTTSVILLE
State	:	MD
Zip	:	21104-1417
Country	:	US
Telephone Number	:	410-878-2211
Fax Number	:

Provider Business Practice Location Address
First Line	:	1134 N ROLLING RD
Second Line	:
City	:	CATONSVILLE
State	:	MD
Zip	:	21228-3826
Country	:	US
Telephone Number	:	410-788-4555
Fax Number	:	410-744-0142

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

Provider Enumeration Date	:	03/27/2007
Last Update Date	:	07/08/2007

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