Healthcare Provider Details

I. General information

NPI: 1720165194
Provider Name (Legal Business Name): JOHN JEFFERSON ZILLMAN D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3507 S 4TH ST
LEAVENWORTH KS
66048-5013
US

IV. Provider business mailing address

3507 S 4TH ST
LEAVENWORTH KS
66048-5013
US

V. Phone/Fax

Practice location:
  • Phone: 913-682-1000
  • Fax: 913-682-6131
Mailing address:
  • Phone: 913-682-1000
  • Fax: 913-682-6131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5657
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: