Provider Demographics
NPI:1659876209
Name:ZIEBA, TINA LEE (DMD)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:LEE
Last Name:ZIEBA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 S GOMAS CT
Mailing Address - Street 2:
Mailing Address - City:DURAND
Mailing Address - State:MI
Mailing Address - Zip Code:48429-1762
Mailing Address - Country:US
Mailing Address - Phone:989-721-1124
Mailing Address - Fax:
Practice Address - Street 1:20737 E 13 MILE RD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4503
Practice Address - Country:US
Practice Address - Phone:586-294-7810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-27
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI2901023220122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program