1811169071 NPI number — C. MICHAEL LOCKE, D.M.D.,M.D.,PLC

Table of content: (NPI 1811169071)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811169071 NPI number — C. MICHAEL LOCKE, D.M.D.,M.D.,PLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
C. MICHAEL LOCKE, D.M.D.,M.D.,PLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811169071
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
125 LEDFORD MILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TULLAHOMA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37388-2278
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-455-2105
Provider Business Mailing Address Fax Number:
931-455-2104

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 LEDFORD MILL RD STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TULLAHOMA
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37388-8262
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-455-2105
Provider Business Practice Location Address Fax Number:
931-455-2104
Provider Enumeration Date:
03/27/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LOCKE
Authorized Official First Name:
C.
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
931-455-2105

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  DS0000007685 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4013636 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 79318 . This is a "UPIN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 338420 . This is a "UNITED CONCORDIA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3208948 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".