Healthcare Provider Details

I. General information

NPI: 1326123464
Provider Name (Legal Business Name): GLENN JON ZIMMER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2241 THEODORE ST
CREST HILL IL
60435-1881
US

IV. Provider business mailing address

335 OLIN CT
ALGONQUIN IL
60102-3122
US

V. Phone/Fax

Practice location:
  • Phone: 815-741-1700
  • Fax:
Mailing address:
  • Phone: 847-204-2725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019-0187542
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: