Provider Demographics
NPI:1649709858
Name:LOCKHART, ANDREA M (DDS)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:M
Last Name:LOCKHART
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 WETZEL ST
Mailing Address - Street 2:
Mailing Address - City:NEW MARTINSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26155-1506
Mailing Address - Country:US
Mailing Address - Phone:304-673-7233
Mailing Address - Fax:
Practice Address - Street 1:700 KEVIN DR
Practice Address - Street 2:
Practice Address - City:NEW MARTINSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26155-2757
Practice Address - Country:US
Practice Address - Phone:304-455-2030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-09
Last Update Date:2020-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV4271122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist