=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376515387
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FARRA MARLENE ISAACSON DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2006
-----------------------------------------------------
Last Update Date | 11/05/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1150 PORTION RD SUITE 15
-----------------------------------------------------
City | HOLTSVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-696-3820
-----------------------------------------------------
Fax | 631-696-7780
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1150 PORTION RD. SUITE 15
-----------------------------------------------------
City | HOLTSVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-696-3820
-----------------------------------------------------
Fax | 631-696-7780
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 049280
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------