MEDICARE: ISSA DENTAL CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist

General Provider Information

NPI Number	:	1134963325
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ISSA DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	4440 E VILLAGE RD
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90808-1540
Country	:	US
Telephone Number	:	624-253-3115
Fax Number	:

Provider Business Practice Location Address
First Line	:	3903 N VIRGINIA RD
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90807
Country	:	US
Telephone Number	:	562-424-8537
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. TIKLAT ISSA
Credential	:	DDS
Telephone Number	:	562-424-8537

Provider Enumeration Date	:	06/21/2024
Last Update Date	:	06/21/2024

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Directions to “ISSA DENTAL CORPORATION ” Practice Location

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