Provider Demographics
NPI:1801271317
Name:MIRZA, ANNIE (DDS)
Entity type:Individual
Prefix:DR
First Name:ANNIE
Middle Name:
Last Name: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 1:1421 N LEWIS AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-1757
Mailing Address - Country:US
Mailing Address - Phone:224-419-7905
Mailing Address - Fax:
Practice Address - Street 1:1421 N LEWIS AVE
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-1757
Practice Address - Country:US
Practice Address - Phone:224-419-7905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-26
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX312591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice