Basic Information
| Provider Information | |||||||||
| NPI: | 1710040035 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOCKETT | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | EARL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3020 14TH ST NW | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200096865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2027454300 | ||||||||
| FaxNumber: | 2022320723 | ||||||||
| Practice Location | |||||||||
| Address1: | 3020 14TH ST NW | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200096865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2027454300 | ||||||||
| FaxNumber: | 2022320723 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DEN4395 | DC | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 024918300 | 05 | DC | MEDICAID |