Healthcare Provider Details

I. General information

NPI: 1376515387
Provider Name (Legal Business Name): FARRA MARLENE ISAACSON DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2006
Last Update Date: 11/05/2020
Certification Date: 11/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 PORTION RD SUITE 15
HOLTSVILLE NY
11742
US

IV. Provider business mailing address

1150 PORTION RD. SUITE 15
HOLTSVILLE NY
11742
US

V. Phone/Fax

Practice location:
  • Phone: 631-696-3820
  • Fax: 631-696-7780
Mailing address:
  • Phone: 631-696-3820
  • Fax: 631-696-7780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number049280
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: