Provider Demographics
NPI:1346627445
Name:CARLISLE, WESLEY D (MD, DMD)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:D
Last Name:CARLISLE
Suffix:
Gender:M
Credentials:MD, DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 SHREVEPORT BARKSDALE HWY
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-2205
Mailing Address - Country:US
Mailing Address - Phone:318-865-0249
Mailing Address - Fax:318-869-0026
Practice Address - Street 1:915 SHREVEPORT BARKSDALE HWY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-2205
Practice Address - Country:US
Practice Address - Phone:318-865-0249
Practice Address - Fax:318-869-0026
Is Sole Proprietor?:No
Enumeration Date:2015-04-28
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA72561223S0112X
LA302556204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery