Provider Demographics
NPI:1720092489
Name:ZIEBA, CHARLES MARCUS (DMD)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:MARCUS
Last Name:ZIEBA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16111 MANCHESTER ROAD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ELLISVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63011
Mailing Address - Country:US
Mailing Address - Phone:636-391-6030
Mailing Address - Fax:636-527-8386
Practice Address - Street 1:16111 MANCHESTER ROAD
Practice Address - Street 2:SUITE 202
Practice Address - City:ELLISVILLE
Practice Address - State:MO
Practice Address - Zip Code:63011
Practice Address - Country:US
Practice Address - Phone:636-391-6030
Practice Address - Fax:636-527-8386
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000169958122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist