Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DT-DO-161070 | OR |
NPI | 1255540852 |
---|---|
Provider Name | Mr. Corey Dean Zimmerman |
First Address | Dallas, OR 97338-3312 |
Second Address | Dallas, OR 97338-3312 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/05/2007 |
Last Update Date | 08/07/2007 |