Provider Demographics
NPI:1942379532
Name:PROSSER, SIMON PATRICK (DDS)
Entity type:Individual
Prefix:DR
First Name:SIMON
Middle Name:PATRICK
Last Name:PROSSER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2103 W PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204
Mailing Address - Country:US
Mailing Address - Phone:509-744-3244
Mailing Address - Fax:509-744-8554
Practice Address - Street 1:2103 W PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204
Practice Address - Country:US
Practice Address - Phone:509-744-3244
Practice Address - Fax:509-744-8554
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00009231122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5044524Medicaid
1458405OtherUNITED CONCORDIA