Provider Demographics
NPI:1235748864
Name:MIRZA, KAZIM ALI
Entity Type:Individual
Prefix:
First Name:KAZIM
Middle Name:ALI
Last Name:MIRZA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 52675
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92619-2675
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:704 BLOSSOM HILL RD STE 107
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95123-5403
Practice Address - Country:US
Practice Address - Phone:408-225-7010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-29
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105131122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist