Provider Demographics
NPI:1902965288
Name:ZIMMERMAN, KENNETH DEAN (DDS)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:DEAN
Last Name:ZIMMERMAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 37
Mailing Address - Street 2:21 NE FRONTAGE RD
Mailing Address - City:BYRON
Mailing Address - State:MN
Mailing Address - Zip Code:55920
Mailing Address - Country:US
Mailing Address - Phone:507-775-6445
Mailing Address - Fax:507-775-6446
Practice Address - Street 1:21 FRONTAGE RD NE
Practice Address - Street 2:
Practice Address - City:BYRON
Practice Address - State:MN
Practice Address - Zip Code:55920-1592
Practice Address - Country:US
Practice Address - Phone:507-775-6445
Practice Address - Fax:507-775-6446
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN83991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice