Provider Demographics
NPI:1033518154
Name:MIRUS ORAL HEALTH & ESTHETIC, LLC
Entity Type:Organization
Organization Name:MIRUS ORAL HEALTH & ESTHETIC, LLC
Other - Org Name:CORNERSTONE DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SYED
Authorized Official - Middle Name:
Authorized Official - Last Name:REHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-915-2827
Mailing Address - Street 1:1530 LAKE ST STE D
Mailing Address - Street 2:
Mailing Address - City:ROSELLE
Mailing Address - State:IL
Mailing Address - Zip Code:60172-3330
Mailing Address - Country:US
Mailing Address - Phone:630-529-0900
Mailing Address - Fax:
Practice Address - Street 1:1530 LAKE ST
Practice Address - Street 2:
Practice Address - City:ROSELLE
Practice Address - State:IL
Practice Address - Zip Code:60172-3330
Practice Address - Country:US
Practice Address - Phone:630-529-0900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-14
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019030260OtherIL DENTAL LICENSE