Provider Demographics
NPI:1366427825
Name:ZIMMERMAN, BRUCE JOHN (DDS)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:JOHN
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 1:1155 KELLY JOHNSON BLVD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-3932
Mailing Address - Country:US
Mailing Address - Phone:719-593-9100
Mailing Address - Fax:719-593-9101
Practice Address - Street 1:1155 KELLY JOHNSON BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-3932
Practice Address - Country:US
Practice Address - Phone:719-593-9100
Practice Address - Fax:719-593-9101
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO104358122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02043586Medicaid
U47948Medicare UPIN
99695Medicare ID - Type Unspecified