Provider Demographics
NPI:1265261937
Name:MIRZA, TARIQ (DMD)
Entity type:Individual
Prefix:DR
First Name:TARIQ
Middle Name:
Last Name:MIRZA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7516 CITY AVE STE 15
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19151-2102
Mailing Address - Country:US
Mailing Address - Phone:215-877-3322
Mailing Address - Fax:
Practice Address - Street 1:7516 CITY AVE STE 15
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19151-2102
Practice Address - Country:US
Practice Address - Phone:215-877-3322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-30
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI03002700122300000X
PADS0446371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist