Provider Demographics
NPI:1376029397
Name:SHERWOOD, CARISSA LEE (DMD)
Entity Type:Individual
Prefix:DR
First Name:CARISSA
Middle Name:LEE
Last Name:SHERWOOD
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:CARISSA
Other - Middle Name:LEE
Other - Last Name:SMARDO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:584 CLEARWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-7206
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3500 BLACK FOREST DR STE 1
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72704-6551
Practice Address - Country:US
Practice Address - Phone:479-888-5119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-12
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20180179441223G0001X
AR45101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice