Healthcare Provider Details

I. General information

NPI: 1720002942
Provider Name (Legal Business Name): JAMES ALLEN SISSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 04/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7550 S. STATE ROAD 67
PENDLETON IN
46064-9280
US

IV. Provider business mailing address

7550 S. STATE ROAD 67
PENDLETON IN
46064-9280
US

V. Phone/Fax

Practice location:
  • Phone: 765-778-2700
  • Fax: 765-778-8600
Mailing address:
  • Phone: 765-778-2700
  • Fax: 765-778-8600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12010191
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: