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General NPI Number Information
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NPI Number | 1013386598
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Entity Type | Organization
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Legal Business Name | 16111 MANCHESTER ROAD, L.L.C.
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Dates
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Enumeration Date | 09/15/2015
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Last Update Date | 09/15/2015
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Provider Practice Location Address
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Address Line | 428 OLD STATE RD.
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City | ELLISVILLE
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State | MO
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Zip | 63021
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Country | US
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Telephone | 636-391-6030
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Fax | 636-527-8386
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Provider Business Mailing Address
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Address Line | 428 OLD STATE RD.
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City | ELLISVILLE
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State | MO
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Zip | 63021
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Country | US
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Telephone | 636-391-6030
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Fax | 636-527-8386
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Authorized Official
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Title or Position | DENTIST/OWNER
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Name | MR. CHARLES M. ZIEBA
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Credential | DMD
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Telephone | 636-391-6030
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2000165488
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2000169958
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License Number State | MO
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