Provider Demographics
NPI:1477755338
Name:ROBERT R. CARLISLE, D.D.S.
Entity Type:Organization
Organization Name:ROBERT R. CARLISLE, D.D.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:R
Authorized Official - Last Name:CARLISLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-776-0564
Mailing Address - Street 1:818 W SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-4162
Mailing Address - Country:US
Mailing Address - Phone:501-776-0564
Mailing Address - Fax:
Practice Address - Street 1:818 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-4162
Practice Address - Country:US
Practice Address - Phone:501-776-0564
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR25011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR58939OtherBLUE CROSS BLUE SHIELD
AR675447OtherUNITED CONCORDIA