Healthcare Provider Details

I. General information

NPI: 1972067569
Provider Name (Legal Business Name): SISSON FAMILY DENTISTRY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2019
Last Update Date: 02/03/2020
Certification Date: 02/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7550 S STATE ROAD 67
PENDLETON IN
46064-8961
US

IV. Provider business mailing address

7550 S STATE ROAD 67
PENDLETON IN
46064-8961
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 Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JAMES A SISSON
Title or Position: OWNER
Credential: DDS
Phone: 765-778-2700