Healthcare Provider Details

I. General information

NPI: 1245722479
Provider Name (Legal Business Name): SAMUEL REED ZIMMER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2018
Last Update Date: 06/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 E WELLS ST STE F
ASH GROVE MO
65604-7374
US

IV. Provider business mailing address

5944 E FARM ROAD 186
ROGERSVILLE MO
65742-6433
US

V. Phone/Fax

Practice location:
  • Phone: 417-751-9772
  • Fax: 417-751-9186
Mailing address:
  • Phone: 417-569-4083
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2018017727
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: