Healthcare Provider Details

I. General information

NPI: 1578211728
Provider Name (Legal Business Name): BRADY MATHEW ZITTLEMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2022
Last Update Date: 06/20/2022
Certification Date: 06/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 3RD AVE NW
MANDAN ND
58554-3130
US

IV. Provider business mailing address

907 21ST ST SE
MANDAN ND
58554-5057
US

V. Phone/Fax

Practice location:
  • Phone: 701-663-7545
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2474
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: