Provider Demographics
NPI:1073351466
Name:ISSA, MARIAM
Entity type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:ISSA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 RICK FRANCIS ST # 24002
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79905-2817
Mailing Address - Country:US
Mailing Address - Phone:915-215-6700
Mailing Address - Fax:
Practice Address - Street 1:222 RICK FRANCIS ST # 24002
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905-2817
Practice Address - Country:US
Practice Address - Phone:915-215-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-18
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX403681223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics