Provider Demographics
NPI:1972067569
Name:SISSON FAMILY DENTISTRY INC
Entity Type:Organization
Organization Name:SISSON FAMILY DENTISTRY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:SISSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:765-778-2700
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:46064-8961
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:46064-8961
Practice Address - Country:US
Practice Address - Phone:765-778-2700
Practice Address - Fax:765-778-8600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-28
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200242770AMedicaid