Healthcare Provider Details

I. General information

NPI: 1790421725
Provider Name (Legal Business Name): ISSA DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2022
Last Update Date: 05/11/2022
Certification Date: 05/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 E VILLAGE RD
LONG BEACH CA
90808-1540
US

IV. Provider business mailing address

4440 E VILLAGE RD
LONG BEACH CA
90808-1540
US

V. Phone/Fax

Practice location:
  • Phone: 562-425-3311
  • Fax:
Mailing address:
  • Phone: 562-425-3311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. TIKLAT ISSA
Title or Position: DENTIST
Credential: DDS
Phone: 562-425-3311