Provider Demographics
NPI:1417339698
Name:LEVINE-SISSON, JACOB (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:LEVINE-SISSON
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 1:101 W READ ST
Mailing Address - Street 2:APT. 303
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-4912
Mailing Address - Country:US
Mailing Address - Phone:301-461-2555
Mailing Address - Fax:
Practice Address - Street 1:5415 W CEDAR LN
Practice Address - Street 2:SUITE 108-B
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-1515
Practice Address - Country:US
Practice Address - Phone:301-530-4502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-24
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15955122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist