Provider Demographics
NPI:1710977939
Name:MIRZA, MUZAFFAR (DDS)
Entity Type:Individual
Prefix:DR
First Name:MUZAFFAR
Middle Name:
Last Name:MIRZA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60609-3758
Mailing Address - Country:US
Mailing Address - Phone:773-548-0600
Mailing Address - Fax:773-548-0740
Practice Address - Street 1:4501 S STATE ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60609-3758
Practice Address - Country:US
Practice Address - Phone:773-548-0600
Practice Address - Fax:773-548-0740
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-27
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019019459122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist