Provider Demographics
NPI:1831180355
Name:CLISTER, KAREN NADINE (DDS)
Entity type:Individual
Prefix:DR
First Name:KAREN
Middle Name:NADINE
Last Name:CLISTER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 E NAPIER AVE
Mailing Address - Street 2:
Mailing Address - City:BENTON HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49022-3900
Mailing Address - Country:US
Mailing Address - Phone:269-925-2113
Mailing Address - Fax:269-925-2191
Practice Address - Street 1:1220 E NAPIER AVE
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-3900
Practice Address - Country:US
Practice Address - Phone:269-925-2113
Practice Address - Fax:269-925-2191
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI14250122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI14250OtherMICHIGAN LICENSE NUMBER
MI014250OtherBCBS PROVIDER ID
MI4230680Medicaid