Healthcare Provider Details

I. General information

NPI: 1467427625
Provider Name (Legal Business Name): JOHN THOMAS ZIMMER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 12/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 LAKE TRAVERSE DRIVE
SISSETON SD
57262
US

IV. Provider business mailing address

100 LAKE TRAVERSE DRIVE
SISSETON SD
57262
US

V. Phone/Fax

Practice location:
  • Phone: 605-742-3676
  • Fax: 605-742-3887
Mailing address:
  • Phone: 605-742-3676
  • Fax: 605-742-3887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number5382
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number5382
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: