Provider Demographics
NPI:1407322043
Name:ZIEBA DENTISTRY LINCOLN SQUARE LTD.
Entity Type:Organization
Organization Name:ZIEBA DENTISTRY LINCOLN SQUARE LTD.
Other - Org Name:CORNERSTONE DENTAL OF LINCOLN SQUARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GREGOIRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-727-4077
Mailing Address - Street 1:2328 W FOSTER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-1826
Mailing Address - Country:US
Mailing Address - Phone:737-654-3575
Mailing Address - Fax:
Practice Address - Street 1:2328 W FOSTER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-1826
Practice Address - Country:US
Practice Address - Phone:773-654-3575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-22
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty