Provider Demographics
NPI:1396189270
Name:PINNACLE PERIODONTICS
Entity Type:Organization
Organization Name:PINNACLE PERIODONTICS
Other - Org Name:PINNACLE PERIODONTICS & DENTAL IMPLANT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PERIODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:D
Authorized Official - Last Name:CARLISLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:501-225-4644
Mailing Address - Street 1:1225 BRECKENRIDGE DR
Mailing Address - Street 2:#110
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-1558
Mailing Address - Country:US
Mailing Address - Phone:501-225-4644
Mailing Address - Fax:501-225-4102
Practice Address - Street 1:1225 BRECKENRIDGE DR
Practice Address - Street 2:#110
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-1558
Practice Address - Country:US
Practice Address - Phone:501-225-4644
Practice Address - Fax:501-225-4102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-23
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR36131223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR195700679Medicaid