Provider Demographics
NPI:1952579724
Name:ZIZMOR, MATTHEW L (DDS)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:L
Last Name:ZIZMOR
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1244 BOYLSTON ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:CHESTNUT HILL
Mailing Address - State:MA
Mailing Address - Zip Code:02467-2116
Mailing Address - Country:US
Mailing Address - Phone:617-738-4788
Mailing Address - Fax:
Practice Address - Street 1:1244 BOYLSTON ST
Practice Address - Street 2:SUITE 205
Practice Address - City:CHESTNUT HILL
Practice Address - State:MA
Practice Address - Zip Code:02467-2116
Practice Address - Country:US
Practice Address - Phone:617-738-4788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-14
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA137811223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX05193OtherBLUE CROSS BLUE SHIELD