Provider Demographics
NPI:1275960312
Name:SISCO FAMILY DENTISTRY
Entity Type:Organization
Organization Name:SISCO FAMILY DENTISTRY
Other - Org Name:JAMESTOWN FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:W
Authorized Official - Last Name:SISCO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:931-879-9544
Mailing Address - Street 1:PO BOX 884
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38556-0884
Mailing Address - Country:US
Mailing Address - Phone:931-879-9544
Mailing Address - Fax:931-879-0844
Practice Address - Street 1:240 CENTRAL AVE. WEST
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:TN
Practice Address - Zip Code:38556-0884
Practice Address - Country:US
Practice Address - Phone:931-879-9544
Practice Address - Fax:931-879-0844
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SISCO FAMILY DENTISTRY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-10-03
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1528728Medicaid