Provider Demographics
NPI:1710016431
Name:TISON, AGNES C (DDS)
Entity Type:Individual
Prefix:
First Name:AGNES
Middle Name:C
Last Name:TISON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 N VIRGIL AVENUE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90029-2016
Mailing Address - Country:US
Mailing Address - Phone:323-665-1208
Mailing Address - Fax:323-665-1203
Practice Address - Street 1:1112 N VIRGIL AVENUE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029-2016
Practice Address - Country:US
Practice Address - Phone:323-665-1208
Practice Address - Fax:323-665-1203
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA425291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice