Provider Demographics
NPI:1538336797
Name:DR. KAREN N CLISTER DDS PC
Entity type:Organization
Organization Name:DR. KAREN N CLISTER DDS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:N
Authorized Official - Last Name:CLISTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:269-925-2113
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI14250122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4230680Medicaid