MEDICARE: DR. TIKLAT ISSA D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	101254	CA

General Provider Information

NPI Number	:	1790217669
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TIKLAT ISSA D.D.S.

Provider Business Mailing Address
First Line	:	4440 E VILLAGE RD
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90808-1540
Country	:	US
Telephone Number	:	166-164-5840
Fax Number	:

Provider Business Practice Location Address
First Line	:	4440 E VILLAGE RD
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90808-1540
Country	:	US
Telephone Number	:	562-425-3311
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/30/2017
Last Update Date	:	05/11/2022

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