MEDICARE: MR. COREY DEAN ZIMMERMAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122400000X	Denturist	DT-DO-161070	OR

General Provider Information

NPI Number	:	1255540852
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. COREY DEAN ZIMMERMAN

Provider Business Mailing Address
First Line	:	322 MAIN ST
Second Line	:	SUITE 110
City	:	DALLAS
State	:	OR
Zip	:	97338-3312
Country	:	US
Telephone Number	:	503-623-8846
Fax Number	:	503-623-8846

Provider Business Practice Location Address
First Line	:	322 MAIN ST
Second Line	:	SUITE 110
City	:	DALLAS
State	:	OR
Zip	:	97338-3312
Country	:	US
Telephone Number	:	503-623-8846
Fax Number	:	503-623-8846

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/21/2007
Last Update Date	:	07/08/2007

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Directions to “ MR. COREY DEAN ZIMMERMAN ” Practice Location

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