MEDICARE: TAVIAN 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	12736	NC
2	1223G0001X	General Practice Dentistry	12014152A	IN
3	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1851038384
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAVIAN SIMMONS DDS

Provider Business Mailing Address
First Line	:	6729 STANHOPE DR
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46254
Country	:	US
Telephone Number	:	252-642-4822
Fax Number	:

Provider Business Practice Location Address
First Line	:	550 N. UNIVERSITY BLVD STE. 3195
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46202-0001
Country	:	US
Telephone Number	:	317-274-5315
Fax Number	:

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

Provider Enumeration Date	:	05/16/2022
Last Update Date	:	06/26/2023

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