Healthcare Provider Details

I. General information

NPI: 1306298104
Provider Name (Legal Business Name): BRANDON LEE ZIMMER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2016
Last Update Date: 07/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5047 VIRGINIA AVE BLDG 500
FORT LEONARD WOOD MO
65473-9126
US

IV. Provider business mailing address

5047 VIRGINIA AVE BLDG 500
FORT LEONARD WOOD MO
65473-9126
US

V. Phone/Fax

Practice location:
  • Phone: 573-596-0408
  • Fax: 573-596-0314
Mailing address:
  • Phone: 573-596-0408
  • Fax: 573-596-0314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: