MEDICARE: DR. LYNN DAVID CARLISLE D.D.S.

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	1223G0001X	General Practice Dentistry	3445	CO

General Provider Information

NPI Number	:	1255316014
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LYNN DAVID CARLISLE D.D.S.

Provider Business Mailing Address
First Line	:	2626 N MESA ST
Second Line	:	364
City	:	EL PASO
State	:	TX
Zip	:	79902-3130
Country	:	US
Telephone Number	:	970-310-6328
Fax Number	:

Provider Business Practice Location Address
First Line	:	128 CHAFFEE RD.
Second Line	:
City	:	FORT BLISS
State	:	TX
Zip	:	79906-3811
Country	:	US
Telephone Number	:	915-568-5001
Fax Number	:	915-568-5174

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/14/2005
Last Update Date	:	07/08/2007

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