Provider Demographics
NPI:1053753061
Name:ISSA, YASIR RIADH (DDS)
Entity type:Individual
Prefix:DR
First Name:YASIR
Middle Name:RIADH
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 1:3137 PUTTER CT
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-9572
Mailing Address - Country:US
Mailing Address - Phone:317-612-4549
Mailing Address - Fax:
Practice Address - Street 1:1320 GOLF RD
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60087-4831
Practice Address - Country:US
Practice Address - Phone:847-336-2800
Practice Address - Fax:847-662-0163
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-19
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0295051223G0001X, 122300000X
IN12011992A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty