Provider Demographics
NPI:1780811828
Name:ZIMMERMAN FAMILY DENTISTRY
Entity type:Organization
Organization Name:ZIMMERMAN FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EMMETT
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:ZIMMERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:228-255-4355
Mailing Address - Street 1:13165 VIDALIA RD
Mailing Address - Street 2:
Mailing Address - City:PASS CHRISTIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39571-9162
Mailing Address - Country:US
Mailing Address - Phone:228-255-4355
Mailing Address - Fax:228-255-6761
Practice Address - Street 1:13165 VIDALIA RD
Practice Address - Street 2:
Practice Address - City:PASS CHRISTIAN
Practice Address - State:MS
Practice Address - Zip Code:39571-9162
Practice Address - Country:US
Practice Address - Phone:228-255-4355
Practice Address - Fax:228-255-6761
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ZIMMERMAN FAMILY DENTISTRY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-06-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3387-061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty