Provider Demographics
NPI:1720577505
Name:ISSA, SAM AYAD (BDS, HDD)
Entity Type:Individual
Prefix:DR
First Name:SAM
Middle Name:AYAD
Last Name:ISSA
Suffix:
Gender:M
Credentials:BDS, HDD
Other - Prefix:DR
Other - First Name:OSAMAH
Other - Middle Name:AYAD
Other - Last Name:ALRIFAIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:29809 SOUTHWELL LN
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33543-4138
Mailing Address - Country:US
Mailing Address - Phone:971-205-0887
Mailing Address - Fax:
Practice Address - Street 1:410 W BLOOMINGDALE AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-7402
Practice Address - Country:US
Practice Address - Phone:813-654-0037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-07
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61029044122300000X
390200000X
FLDN25441122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program