Provider Demographics
NPI:1447705348
Name:LOCKMAN, CHARISA (RDH)
Entity type:Individual
Prefix:
First Name:CHARISA
Middle Name:
Last Name:LOCKMAN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 65
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365-0017
Mailing Address - Country:US
Mailing Address - Phone:541-961-4802
Mailing Address - Fax:
Practice Address - Street 1:422 GIBSON LN
Practice Address - Street 2:
Practice Address - City:LOGSDEN
Practice Address - State:OR
Practice Address - Zip Code:97357-9713
Practice Address - Country:US
Practice Address - Phone:541-961-4802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-20
Last Update Date:2016-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH4652124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist