Basic Information
| Provider Information | |||||||||
| NPI: | 1548486566 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOCKWOOD DENTAL ASSCOCIATES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14 LOCKWOOD DRIVE | ||||||||
| Address2: | STE A | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437228500 | ||||||||
| FaxNumber: | 8437208555 | ||||||||
| Practice Location | |||||||||
| Address1: | 14 LOCKWOOD DRIVE | ||||||||
| Address2: | STE A | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437228500 | ||||||||
| FaxNumber: | 8437208555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MODZELEWSKI | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
| AuthorizedOfficialMiddleName: | STEVEN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8437228500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DMD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 3892 | SC | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 1223G0001X | 1313 | SC | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | ZX3892 | 05 | SC | MEDICAID | Z13138 | 05 | SC | MEDICAID |