MEDICARE: DR. LESLIE N SIMON D.D.S.

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	027761	NY

General Provider Information

NPI Number	:	1538163894
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LESLIE N SIMON D.D.S.

Provider Business Mailing Address
First Line	:	PO BOX 273
Second Line	:
City	:	CROSS RIVER
State	:	NY
Zip	:	10518-0273
Country	:	US
Telephone Number	:	914-763-5892
Fax Number	:	914-763-8693

Provider Business Practice Location Address
First Line	:	787 ROUTE 35
Second Line	:
City	:	CROSS RIVER
State	:	NY
Zip	:	10518-1109
Country	:	US
Telephone Number	:	914-763-5892
Fax Number	:	914-763-8693

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

Provider Enumeration Date	:	06/02/2005
Last Update Date	:	07/08/2007

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