Provider Demographics
NPI:1497195549
Name:SISSON, TAVIS M (DMD)
Entity Type:Individual
Prefix:DR
First Name:TAVIS
Middle Name:M
Last Name:SISSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5122 DR PHILLIPS BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-3312
Mailing Address - Country:US
Mailing Address - Phone:407-434-8344
Mailing Address - Fax:
Practice Address - Street 1:5122 DR PHILLIPS BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-3312
Practice Address - Country:US
Practice Address - Phone:407-434-8344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-02
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN202241223E0200X
TN115071223E0200X
FLDN 202241223G0001X
SCDGD.8284 GD1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No1223G0001XDental ProvidersDentistGeneral Practice