Basic Information
| Provider Information | |||||||||
| NPI: | 1437718301 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARLISLE | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | DANIEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 822 SHIP ST APT 5 | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490851138 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 800 M 139 | ||||||||
| Address2: | |||||||||
| City: | BENTON HARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490223881 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8558696900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2019 | ||||||||
| LastUpdateDate: | 06/13/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 2901600138 | MI | Y | Dental Providers | Dentist |
No ID Information.