Healthcare Provider Details

I. General information

NPI: 1356538656
Provider Name (Legal Business Name): MATTHEW DAVID CARLISLE D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2007
Last Update Date: 02/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 BRECKENRIDGE DR SUITE #210
LITTLE ROCK AR
72205-1558
US

IV. Provider business mailing address

1225 BRECKENRIDGE DR SUITE #210
LITTLE ROCK AR
72205-1558
US

V. Phone/Fax

Practice location:
  • Phone: 501-225-4644
  • Fax: 501-225-4102
Mailing address:
  • Phone: 501-225-4644
  • Fax: 501-225-4102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number3613
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number34
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: