Provider Demographics
NPI:1679868111
Name:SIMONS, KEITH GERARD (DDS)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:GERARD
Last Name:SIMONS
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 1:1204 MERRILL AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401
Mailing Address - Country:US
Mailing Address - Phone:715-842-3704
Mailing Address - Fax:715-842-4207
Practice Address - Street 1:1204 MERRILL AVE
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401
Practice Address - Country:US
Practice Address - Phone:715-842-3704
Practice Address - Fax:715-842-4207
Is Sole Proprietor?:No
Enumeration Date:2011-06-13
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6716015122300000X
WI6716-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist