Healthcare Provider Details

I. General information

NPI: 1679346605
Provider Name (Legal Business Name): MAYCE-ARREEM ISSA DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2023
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2109 W WASHINGTON ST
BROKEN ARROW OK
74012-6801
US

IV. Provider business mailing address

2109 W WASHINGTON ST
BROKEN ARROW OK
74012-6801
US

V. Phone/Fax

Practice location:
  • Phone: 918-455-0123
  • Fax:
Mailing address:
  • Phone: 918-455-0123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8231
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: