Healthcare Provider Details

I. General information

NPI: 1033518154
Provider Name (Legal Business Name): MIRUS ORAL HEALTH & ESTHETIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2014
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 LAKE ST
ROSELLE IL
60172-3330
US

IV. Provider business mailing address

1530 LAKE ST STE D
ROSELLE IL
60172-3330
US

V. Phone/Fax

Practice location:
  • Phone: 630-529-0900
  • Fax:
Mailing address:
  • Phone: 630-529-0900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SYED REHMAN
Title or Position: PRESIDENT/OWNER
Credential: DDS
Phone: 847-915-2827