=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659876209
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TINA LEE ZIEBA DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2018
-----------------------------------------------------
Last Update Date | 06/17/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20737 E 13 MILE RD
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48066-4503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-294-7810
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 708 S GOMAS CT
-----------------------------------------------------
City | DURAND
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48429-1762
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-721-1124
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 2901023220
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------