Provider Demographics
NPI:1538318340
Name:LOCKHART, CODY REED (DDS)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:REED
Last Name:LOCKHART
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:PO BOX 497
Mailing Address - Street 2:
Mailing Address - City:HICO
Mailing Address - State:WV
Mailing Address - Zip Code:25854
Mailing Address - Country:US
Mailing Address - Phone:304-658-5282
Mailing Address - Fax:304-658-5299
Practice Address - Street 1:26496 MIDLAND TRAIL
Practice Address - Street 2:
Practice Address - City:HICO
Practice Address - State:WV
Practice Address - Zip Code:25854
Practice Address - Country:US
Practice Address - Phone:304-658-5282
Practice Address - Fax:304-658-5299
Is Sole Proprietor?:No
Enumeration Date:2008-09-17
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV38231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810013462Medicaid