Healthcare Provider Details

I. General information

NPI: 1689450249
Provider Name (Legal Business Name): MARWA ISSA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2023
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 CLEARVIEW RD
MADISON HEIGHTS VA
24572-2600
US

IV. Provider business mailing address

200 W EDGE WAY APT 3109
LYNCHBURG VA
24502-5858
US

V. Phone/Fax

Practice location:
  • Phone: 434-929-1400
  • Fax:
Mailing address:
  • Phone: 929-353-4547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number0401418633
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401418633
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: