Provider Demographics
NPI:1922835024
Name:DAOUI, ISSA WISSAM (DMD)
Entity type:Individual
Prefix:
First Name:ISSA
Middle Name:WISSAM
Last Name:DAOUI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2302 HUDSON SQ # 2302
Mailing Address - Street 2:
Mailing Address - City:COHOES
Mailing Address - State:NY
Mailing Address - Zip Code:12047-3773
Mailing Address - Country:US
Mailing Address - Phone:514-804-8942
Mailing Address - Fax:
Practice Address - Street 1:231 WADE ROAD EXT STE 101
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-1855
Practice Address - Country:US
Practice Address - Phone:518-782-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-14
Last Update Date:2024-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0639651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice