Provider Demographics
NPI:1093163503
Name:ZIEMBA, MARK JAMES (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JAMES
Last Name:ZIEMBA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5470 LAFAYETTE RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-1620
Mailing Address - Country:US
Mailing Address - Phone:317-293-4611
Mailing Address - Fax:
Practice Address - Street 1:5470 LAFAYETTE RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-1620
Practice Address - Country:US
Practice Address - Phone:317-293-4611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-25
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012502A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice