=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689450249
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARWA ISSA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2023
-----------------------------------------------------
Last Update Date | 05/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 109 CLEARVIEW RD
-----------------------------------------------------
City | MADISON HEIGHTS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24572-2600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-929-1400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 W EDGE WAY APT 3109
-----------------------------------------------------
City | LYNCHBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24502-5858
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 929-353-4547
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 0401418633
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 0401418633
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------