MEDICARE: DR. YAHAZIEL SIMON D.M.D.

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	DN015206	GA
2	122300000X	Dentist	DN015206	GA

General Provider Information

NPI Number	:	1649720079
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. YAHAZIEL SIMON D.M.D.

Provider Business Mailing Address
First Line	:	PO BOX 952
Second Line	:
City	:	FOREST PARK
State	:	GA
Zip	:	30298-0952
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4763 ATLANTA HWY STE 380
Second Line	:
City	:	LOGANVILLE
State	:	GA
Zip	:	30052-6793
Country	:	US
Telephone Number	:	770-962-9560
Fax Number	:

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

Provider Enumeration Date	:	10/10/2016
Last Update Date	:	12/11/2025

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