Healthcare Provider Details

I. General information

NPI: 1336063148
Provider Name (Legal Business Name): LAILA MIRZA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7345 W 25TH ST
NORTH RIVERSIDE IL
60546-1409
US

IV. Provider business mailing address

95 YORKTOWN CTR APT 343
LOMBARD IL
60148-7713
US

V. Phone/Fax

Practice location:
  • Phone: 708-447-0900
  • Fax:
Mailing address:
  • Phone: 713-264-1263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.037407
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: