Provider Demographics
NPI:1225524770
Name:MIRZA, MAHUM ABBAS
Entity Type:Individual
Prefix:
First Name:MAHUM
Middle Name:ABBAS
Last Name:MIRZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3157 FARNAM ST APT 7331
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68131-3544
Mailing Address - Country:US
Mailing Address - Phone:440-391-1878
Mailing Address - Fax:
Practice Address - Street 1:13625 CALIFORNIA ST STE 300
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-5246
Practice Address - Country:US
Practice Address - Phone:402-933-8005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7481122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist