Provider Demographics
NPI:1750461869
Name:LOCKHART, PETER BERGEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:BERGEN
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 1:3300 CHAUCER DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-4871
Mailing Address - Country:US
Mailing Address - Phone:704-556-0522
Mailing Address - Fax:
Practice Address - Street 1:1608 SCOTT AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5848
Practice Address - Country:US
Practice Address - Phone:704-355-4841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5730122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8995368Medicaid
NCU38649Medicare UPIN