Provider Demographics
NPI:1396853644
Name:ZIMMERMAN, KEVIN JAMES (DMD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:JAMES
Last Name:ZIMMERMAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1270 KOT NUM ROAD
Mailing Address - Street 2:PO BOX 1209
Mailing Address - City:WARM SPRINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97761-1209
Mailing Address - Country:US
Mailing Address - Phone:541-553-1196
Mailing Address - Fax:541-553-2135
Practice Address - Street 1:1270 KOT NUM ROAD
Practice Address - Street 2:
Practice Address - City:WARM SPRINGS
Practice Address - State:OR
Practice Address - Zip Code:97761-1209
Practice Address - Country:US
Practice Address - Phone:541-553-1196
Practice Address - Fax:541-553-2135
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS035025122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR273855Medicaid