Provider Demographics
NPI:1306993381
Name:HISSOM, JAMES A
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:A
Last Name:HISSOM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2330 W 38TH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-4564
Mailing Address - Country:US
Mailing Address - Phone:814-835-8300
Mailing Address - Fax:
Practice Address - Street 1:2330 W 38TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506-4564
Practice Address - Country:US
Practice Address - Phone:814-835-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS024068-L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA449685OtherPROVIDER # FOR UNITED CON