Provider Demographics
NPI:1962233890
Name:LILLY, CARTER JAMES (DDS)
Entity type:Individual
Prefix:
First Name:CARTER
Middle Name:JAMES
Last Name:LILLY
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 1:8428 W BECHER ST
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-1722
Mailing Address - Country:US
Mailing Address - Phone:712-560-2802
Mailing Address - Fax:
Practice Address - Street 1:2100 MILLER PARK WAY
Practice Address - Street 2:
Practice Address - City:WEST MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53219-1641
Practice Address - Country:US
Practice Address - Phone:414-645-4540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-12
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6001653-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist