=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255061404
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARINA ISAAC DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2022
-----------------------------------------------------
Last Update Date | 06/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 436 HARMON COVE TOWER
-----------------------------------------------------
City | SECAUCUS
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07094-1752
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-558-0300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 436 HARMON COVE TOWER
-----------------------------------------------------
City | SECAUCUS
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07094-1752
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-558-0300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 22DI02909700
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------