Provider Demographics
NPI:1982198354
Name:MIRZA, TAHA (DDS)
Entity Type:Individual
Prefix:DR
First Name:TAHA
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 1:2105 W SILVERLEAF CT
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:IL
Mailing Address - Zip Code:60101-6403
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:845 S PERRYVILLE RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-4340
Practice Address - Country:US
Practice Address - Phone:779-423-2135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-19
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190317401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice