MEDICARE: REBECCA CARLISLE D.D.S. L.L.C.

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	122300000X	Dentist	3827	AR

General Provider Information

NPI Number	:	1114399946
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REBECCA CARLISLE D.D.S. L.L.C.

Provider Business Mailing Address
First Line	:	1188 N SALEM RD
Second Line	:	STE 10
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72704-8807
Country	:	US
Telephone Number	:	479-527-0707
Fax Number	:

Provider Business Practice Location Address
First Line	:	1188 N SALEM RD
Second Line	:	STE 10
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72704-8807
Country	:	US
Telephone Number	:	479-527-0707
Fax Number	:

Authorized Official
Title or Position	:	DENTIST/OWNER
Name	:	DR. REBECCA CARLISLE
Credential	:	D.D.S.
Telephone Number	:	479-527-0707

Provider Enumeration Date	:	10/20/2015
Last Update Date	:	10/20/2015

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