Provider Demographics
NPI:1437993417
Name:LOCKLEAR, JACOB BRISCO (DDS)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:BRISCO
Last Name:LOCKLEAR
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4306 LUDGATE ST
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-2461
Mailing Address - Country:US
Mailing Address - Phone:910-671-4601
Mailing Address - Fax:
Practice Address - Street 1:4306 LUDGATE ST
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-2461
Practice Address - Country:US
Practice Address - Phone:910-671-4601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13772122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist