Provider Demographics
NPI:1134181779
Name:BAER-MIRZA, CATHERINE M (DDS)
Entity type:Individual
Prefix:
First Name:CATHERINE
Middle Name:M
Last Name:BAER-MIRZA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2715 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61103-3111
Mailing Address - Country:US
Mailing Address - Phone:815-964-8713
Mailing Address - Fax:815-964-3719
Practice Address - Street 1:2715 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-3111
Practice Address - Country:US
Practice Address - Phone:815-964-8713
Practice Address - Fax:815-964-3719
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0192665761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9177538Medicaid