MEDICARE: DR. MITCHELL JACK 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	1223G0001X	General Practice Dentistry	034526	NY

General Provider Information

NPI Number	:	1821026600
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MITCHELL JACK SIMON D.M.D

Provider Business Mailing Address
First Line	:	960 ATLANTIC AVE
Second Line	:
City	:	BALDWIN HARBOR
State	:	NY
Zip	:	11510-4241
Country	:	US
Telephone Number	:	516-377-1818
Fax Number	:	515-377-1831

Provider Business Practice Location Address
First Line	:	960 ATLANTIC AVE
Second Line	:
City	:	BALDWIN HARBOR
State	:	NY
Zip	:	11510-4241
Country	:	US
Telephone Number	:	516-377-1818
Fax Number	:	515-377-1831

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

Provider Enumeration Date	:	06/29/2006
Last Update Date	:	07/08/2007

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