Healthcare Provider Details

I. General information

NPI: 1346627445
Provider Name (Legal Business Name): WESLEY D. CARLISLE MD, DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2015
Last Update Date: 08/19/2021
Certification Date: 08/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 SHREVEPORT BARKSDALE HWY
SHREVEPORT LA
71105-2205
US

IV. Provider business mailing address

915 SHREVEPORT BARKSDALE HWY
SHREVEPORT LA
71105-2205
US

V. Phone/Fax

Practice location:
  • Phone: 318-865-0249
  • Fax: 318-869-0026
Mailing address:
  • Phone: 318-865-0249
  • Fax: 318-869-0026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number7256
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number302556
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: