Provider Demographics
NPI:1245906148
Name:SHREVEPORT CENTER FOR ORAL AND FACIAL SURGERY, L.L.C.
Entity type:Organization
Organization Name:SHREVEPORT CENTER FOR ORAL AND FACIAL SURGERY, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL AND MAXILLOFACIAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:D
Authorized Official - Last Name:CARLISLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD, DMD
Authorized Official - Phone:318-865-0249
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-19
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty