Healthcare Provider Details

I. General information

NPI: 1568875599
Provider Name (Legal Business Name): JASON ZITTERKOPF DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2014
Last Update Date: 07/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 W 36TH ST
SCOTTSBLUFF NE
69361-4654
US

IV. Provider business mailing address

204 W 36TH ST
SCOTTSBLUFF NE
69361-4654
US

V. Phone/Fax

Practice location:
  • Phone: 308-632-7414
  • Fax:
Mailing address:
  • Phone: 308-632-7414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7152
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: