Provider Demographics
NPI:1255540852
Name:ZIMMERMAN, COREY DEAN
Entity type:Individual
Prefix:MR
First Name:COREY
Middle Name:DEAN
Last Name:ZIMMERMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 MAIN ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:DALLAS
Mailing Address - State:OR
Mailing Address - Zip Code:97338-3312
Mailing Address - Country:US
Mailing Address - Phone:503-623-8846
Mailing Address - Fax:503-623-8846
Practice Address - Street 1:322 MAIN ST
Practice Address - Street 2:SUITE 110
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-3312
Practice Address - Country:US
Practice Address - Phone:503-623-8846
Practice Address - Fax:503-623-8846
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
ORDT-DO-161070122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist