Healthcare Provider Details

I. General information

NPI: 1164510103
Provider Name (Legal Business Name): JAY SISON D.D.S., D.M.SC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10921 WILSHIRE BLVD SUITE #611
LOS ANGELES CA
90024-3906
US

IV. Provider business mailing address

10921 WILSHIRE BLVD SUITE #611
LOS ANGELES CA
90024-3906
US

V. Phone/Fax

Practice location:
  • Phone: 310-208-3741
  • Fax: 310-208-4990
Mailing address:
  • Phone: 310-208-3741
  • Fax: 310-208-4990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number45409
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: