Provider Demographics
NPI:1164510103
Name:SISON, JAY (DDS, DMSC)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:
Last Name:SISON
Suffix:
Gender:M
Credentials:DDS, DMSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10921 WILSHIRE BLVD
Mailing Address - Street 2:SUITE #611
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-3906
Mailing Address - Country:US
Mailing Address - Phone:310-208-3741
Mailing Address - Fax:310-208-4990
Practice Address - Street 1:10921 WILSHIRE BLVD
Practice Address - Street 2:SUITE #611
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-3906
Practice Address - Country:US
Practice Address - Phone:310-208-3741
Practice Address - Fax:310-208-4990
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA454091223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics