Basic Information
| Provider Information | |||||||||
| NPI: | 1770933186 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARLISLE | ||||||||
| FirstName: | SARAH | ||||||||
| MiddleName: | S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 365 STOUT DRIVE, BOX 70403 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376141703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234394515 | ||||||||
| FaxNumber: | 4234395780 | ||||||||
| Practice Location | |||||||||
| Address1: | 2151 CENTURY LN | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376044469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239296941 | ||||||||
| FaxNumber: | 4239296972 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2016 | ||||||||
| LastUpdateDate: | 12/18/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 0401415236 | VA | N | Dental Providers | Dentist | 122300000X | 10462 | TN | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 10462 | 01 | TN | LICENSE | OTHER |