Provider Demographics
NPI:1790217669
Name:ISSA, TIKLAT (DDS)
Entity type:Individual
Prefix:DR
First Name:TIKLAT
Middle Name:
Last Name:ISSA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4440 E VILLAGE RD
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90808-1540
Mailing Address - Country:US
Mailing Address - Phone:166-164-5840
Mailing Address - Fax:
Practice Address - Street 1:4440 E VILLAGE RD
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90808-1540
Practice Address - Country:US
Practice Address - Phone:562-425-3311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-30
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101254122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist