Provider Demographics
NPI:1427046788
Name:CAGLE, LISA A (DMD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:A
Last Name:CAGLE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 NORTHPORT DR
Mailing Address - Street 2:LOWER LEVEL EAST
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-5904
Mailing Address - Country:US
Mailing Address - Phone:618-466-5150
Mailing Address - Fax:
Practice Address - Street 1:108 NORTHPORT DR
Practice Address - Street 2:LOWER LEVEL EAST
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-5904
Practice Address - Country:US
Practice Address - Phone:618-466-5150
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X, 1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223P0300XDental ProvidersDentistPeriodontics