MEDICARE: ZIEBA DENTISTRY LINCOLN SQUARE LTD.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1407322043
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ZIEBA DENTISTRY LINCOLN SQUARE LTD.

Provider Business Mailing Address
First Line	:	2328 W FOSTER AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-1826
Country	:	US
Telephone Number	:	737-654-3575
Fax Number	:

Provider Business Practice Location Address
First Line	:	2328 W FOSTER AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-1826
Country	:	US
Telephone Number	:	773-654-3575
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	JONATHAN GREGOIRE
Credential	:
Telephone Number	:	847-727-4077

Provider Enumeration Date	:	10/22/2018
Last Update Date	:	10/25/2019

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