Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | DI11071 | NJ |
NPI | 1083620439 |
---|---|
Provider Name | Dr. Michael Jeffrey Simon |
First Address | East Orange, NJ 07018-1023 |
Second Address | East Orange, NJ 07018-1023 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/07/2006 |
Last Update Date | 08/07/2007 |