Provider Demographics
NPI:1992827760
Name:SISON, EMILIO MEDINA JR (DDS)
Entity Type:Individual
Prefix:
First Name:EMILIO
Middle Name:MEDINA
Last Name:SISON
Suffix:JR
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 1:2500 W LINCOLN AVE
Mailing Address - Street 2:# 2
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801
Mailing Address - Country:US
Mailing Address - Phone:714-761-7062
Mailing Address - Fax:714-761-1470
Practice Address - Street 1:2500 W LINCOLN AVE
Practice Address - Street 2:# 2
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801
Practice Address - Country:US
Practice Address - Phone:714-761-7062
Practice Address - Fax:714-761-1470
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA376171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice