Healthcare Provider Details

I. General information

NPI: 1922835024
Provider Name (Legal Business Name): ISSA WISSAM DAOUI DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2024
Last Update Date: 09/14/2024
Certification Date: 09/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

231 WADE ROAD EXT STE 101
LATHAM NY
12110-1855
US

IV. Provider business mailing address

2302 HUDSON SQ # 2302
COHOES NY
12047-3773
US

V. Phone/Fax

Practice location:
  • Phone: 518-782-1900
  • Fax:
Mailing address:
  • Phone: 514-804-8942
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number063965
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: