Healthcare Provider Details

I. General information

NPI: 1013386598
Provider Name (Legal Business Name): 16111 MANCHESTER ROAD, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2015
Last Update Date: 09/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 OLD STATE RD.
ELLISVILLE MO
63021
US

IV. Provider business mailing address

428 OLD STATE RD.
ELLISVILLE MO
63021
US

V. Phone/Fax

Practice location:
  • Phone: 636-391-6030
  • Fax: 636-527-8386
Mailing address:
  • Phone: 636-391-6030
  • Fax: 636-527-8386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2000165488
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2000169958
License Number StateMO

VIII. Authorized Official

Name: MR. CHARLES M. ZIEBA
Title or Position: DENTIST/OWNER
Credential: DMD
Phone: 636-391-6030