Provider Demographics
NPI:1184721995
Name:LOCKE, C. MICHAEL (DMD, MD)
Entity type:Individual
Prefix:
First Name:C.
Middle Name:MICHAEL
Last Name:LOCKE
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 LEDFORD MILL RD
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-2278
Mailing Address - Country:US
Mailing Address - Phone:931-455-2105
Mailing Address - Fax:931-455-2104
Practice Address - Street 1:125 LEDFORD MILL RD
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-2278
Practice Address - Country:US
Practice Address - Phone:931-455-2105
Practice Address - Fax:931-455-2104
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000031540204E00000X
TNDS00000076851223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN338420OtherUNITED CONCORDIA
TN4013636OtherBLUE CROSS BLUE SHIELD
TN3208948Medicaid
TN79318Medicare UPIN
TN3208948Medicaid