Simon Lucas Mack, D.D.S.

Primary specialty

DentistTaxonomy code 122300000X

License

34781 Issued in TX

Practice address

3004 H.G. Mosley Pkwy
Longview, TX 75605

Phone

(903) 758-3444

Fax

(903) 758-1967

NPI assigned

Apr 11, 2018

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in TX

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Specialty

DentistAlso: Oral Surgery

Education

Other, 2018

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

East Texas Oral and Maxillofacial Surgery Associates IncGroup PAC ID 4981865771, 3 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• East Texas Oral & Maxillofacial Surgery Associates Inc.

  • Oral and Maxillofacial Surgery (Dentist)
  • Longview, TX
  • NPI 1952459307
  Medicare reassignment Care Compare group NPD
• Camp-Mack Enterprises LLC

  • Oral and Maxillofacial Surgery (Dentist)
  • Mount Pleasant, TX
  • NPI 1851796262
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1523404800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1662681600000",
    "number": "1639676166",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3004 H.G. MOSLEY PKWY",
            "city": "LONGVIEW",
            "state": "TX",
            "postal_code": "75605",
            "telephone_number": "903-758-3444",
            "fax_number": "903-758-1967"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3004 H.G. MOSLEY PKWY",
            "city": "LONGVIEW",
            "state": "TX",
            "postal_code": "75605",
            "telephone_number": "903-758-3444",
            "fax_number": "903-758-1967"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "MACK",
        "first_name": "SIMON",
        "middle_name": "LUCAS",
        "name_prefix": "Dr.",
        "credential": "D.D.S.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2018-04-11",
        "last_updated": "2022-09-09",
        "certification_date": "2022-09-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "TX",
            "license": "34781",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• John B Mack, MD
• Kelly Wade Mack, DDS
• Madison Mack, DDS
• Samuel Christopher Mack, D.D.S.
• Shundra Mack
• Susan M Maddox
• Ugochukwu Ikechi Maduforo, MD
• Madysen House Enterprises
• Leigh Ann Mahjoobi, FNP
• Makona SNF, LLC

• Dentist in Longview, TX
• Providers in Longview, TX by specialty
• Dentist in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 9, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.