Provider Demographics
NPI:1194050682
Name:CARLISLE, MICHAEL JOSEPH (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:CARLISLE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10801 BLONDO STREET
Mailing Address - Street 2:SUITE D
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-3800
Mailing Address - Country:US
Mailing Address - Phone:402-493-9361
Mailing Address - Fax:
Practice Address - Street 1:10801 BLONDO STREET
Practice Address - Street 2:SUITE D
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68164-3800
Practice Address - Country:US
Practice Address - Phone:402-493-9361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-16
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE58421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice