Provider Demographics
NPI:1619186400
Name:ZIMMERMAN, DIANE MARIE (DDS)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:ZIMMERMAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 LEXINGTON AVE N
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-8135
Mailing Address - Country:US
Mailing Address - Phone:651-255-8888
Mailing Address - Fax:
Practice Address - Street 1:3200 LEXINGTON AVE N
Practice Address - Street 2:
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-8135
Practice Address - Country:US
Practice Address - Phone:651-255-8888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN101391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice