Provider Demographics
NPI:1013386598
Name:16111 MANCHESTER ROAD, L.L.C.
Entity Type:Organization
Organization Name:16111 MANCHESTER ROAD, L.L.C.
Other - Org Name:ZIEBA FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:M
Authorized Official - Last Name:ZIEBA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:636-391-6030
Mailing Address - Street 1:428 OLD STATE RD.
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63021
Mailing Address - Country:US
Mailing Address - Phone:636-391-6030
Mailing Address - Fax:636-527-8386
Practice Address - Street 1:428 OLD STATE RD.
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MO
Practice Address - Zip Code:63021
Practice Address - Country:US
Practice Address - Phone:636-391-6030
Practice Address - Fax:636-527-8386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-15
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20001699581223G0001X
MO20001654881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty