Provider Demographics
NPI:1578211728
Name:ZITTLEMAN, BRADY MATHEW
Entity Type:Individual
Prefix:
First Name:BRADY
Middle Name:MATHEW
Last Name:ZITTLEMAN
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 1:907 21ST ST SE
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-5057
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:204 3RD AVE NW
Practice Address - Street 2:
Practice Address - City:MANDAN
Practice Address - State:ND
Practice Address - Zip Code:58554-3130
Practice Address - Country:US
Practice Address - Phone:701-663-7545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-16
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND24741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice