Provider Demographics
NPI:1548956980
Name:MUTTER, ZACHARY MICHAEL
Entity type:Individual
Prefix:
First Name:ZACHARY
Middle Name:MICHAEL
Last Name:MUTTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 DUCK HAVEN PT
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-8173
Mailing Address - Country:US
Mailing Address - Phone:314-249-6557
Mailing Address - Fax:
Practice Address - Street 1:910 BERT KOUNS INDUSTRIAL LOOP
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3410
Practice Address - Country:US
Practice Address - Phone:318-686-7470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-17
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA76111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice