Healthcare Provider Details

I. General information

NPI: 1972922599
Provider Name (Legal Business Name): MATTHEW NEILL ZIMMER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2014
Last Update Date: 08/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NICOLLS RD 114 ROCKLAND HALL
STONY BROOK NY
11794
US

IV. Provider business mailing address

122 CAMPANILE DR
MOORESVILLE NC
28117-8605
US

V. Phone/Fax

Practice location:
  • Phone: 631-632-3181
  • Fax:
Mailing address:
  • Phone: 631-327-3957
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number10269
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: