Provider Demographics
NPI:1720002942
Name:SISSON, JAMES ALLEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:ALLEN
Last Name: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 1:7550 S. STATE ROAD 67
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:IN
Mailing Address - Zip Code:46064-9280
Mailing Address - Country:US
Mailing Address - Phone:765-778-2700
Mailing Address - Fax:765-778-8600
Practice Address - Street 1:7550 S. STATE ROAD 67
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:IN
Practice Address - Zip Code:46064-9280
Practice Address - Country:US
Practice Address - Phone:765-778-2700
Practice Address - Fax:765-778-8600
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120101911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200242770Medicaid