Provider Demographics
NPI:1366420762
Name:SIMMONS, MARY ANNE
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:ANNE
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 S RIDGE ST
Mailing Address - Street 2:
Mailing Address - City:PORT SANILAC
Mailing Address - State:MI
Mailing Address - Zip Code:48469-9704
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:245 S RIDGE ST
Practice Address - Street 2:
Practice Address - City:PORT SANILAC
Practice Address - State:MI
Practice Address - Zip Code:48469-9704
Practice Address - Country:US
Practice Address - Phone:810-622-8230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010122181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice