MEDICARE: TISON DENTAL CORPORATION, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1437373859
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TISON DENTAL CORPORATION, INC.

Provider Business Mailing Address
First Line	:	1112 N VIRGIL AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90029-2016
Country	:	US
Telephone Number	:	323-665-1208
Fax Number	:	323-665-1203

Provider Business Practice Location Address
First Line	:	1112 N VIRGIL AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90029-2016
Country	:	US
Telephone Number	:	323-665-1208
Fax Number	:	323-665-1203

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. EMMANUEL TISON
Credential	:
Telephone Number	:	323-665-1208

Provider Enumeration Date	:	04/13/2007
Last Update Date	:	08/22/2020

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