Healthcare Provider Details

I. General information

NPI: 1427046788
Provider Name (Legal Business Name): LISA A CAGLE D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 NORTHPORT DR LOWER LEVEL EAST
ALTON IL
62002-5904
US

IV. Provider business mailing address

108 NORTHPORT DR LOWER LEVEL EAST
ALTON IL
62002-5904
US

V. Phone/Fax

Practice location:
  • Phone: 618-466-5150
  • Fax:
Mailing address:
  • Phone: 618-466-5150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: