Provider Demographics
NPI:1487060265
Name:SIMONTON, DOMINIQUE MARIE (OD)
Entity type:Individual
Prefix:DR
First Name:DOMINIQUE
Middle Name:MARIE
Last Name:SIMONTON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:DOMINIQUE
Other - Middle Name:MARIE
Other - Last Name:OKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:4224 DECATUR AVE N
Mailing Address - Street 2:
Mailing Address - City:NEW HOPE
Mailing Address - State:MN
Mailing Address - Zip Code:55428-4725
Mailing Address - Country:US
Mailing Address - Phone:612-245-3212
Mailing Address - Fax:
Practice Address - Street 1:8251 FLYING CLOUD DR
Practice Address - Street 2:STE 1296
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-5530
Practice Address - Country:US
Practice Address - Phone:952-944-2792
Practice Address - Fax:952-942-4973
Is Sole Proprietor?:No
Enumeration Date:2014-07-01
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3401152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist