Provider Demographics
NPI:1306860234
Name:SIDD, JAMES JENSON JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:JENSON
Last Name:SIDD
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1100 N COLLEGE AVE.
Mailing Address - Street 2:VA MEDICAL CENTER
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:007 CHOOSGAI DRIVE
Practice Address - Street 2:TOHATCHI HEALTH CENTER
Practice Address - City:TOHATCHI
Practice Address - State:NM
Practice Address - Zip Code:87325-1944
Practice Address - Country:US
Practice Address - Phone:505-733-8440
Practice Address - Fax:505-722-1565
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2017-07-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ51761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice