Healthcare Provider Details

I. General information

NPI: 1073070728
Provider Name (Legal Business Name): HAMMOCK, DMD & LOTAKIS, DDS IV, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2019
Last Update Date: 02/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2258 W ROOSEVELT BLVD STE A
MONROE NC
28110-3090
US

IV. Provider business mailing address

5821 FAIRVIEW RD STE 220
CHARLOTTE NC
28209-5601
US

V. Phone/Fax

Practice location:
  • Phone: 704-291-7100
  • Fax:
Mailing address:
  • Phone: 704-522-1550
  • Fax: 704-445-7895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: SIMONE WALSH
Title or Position: VP - ACCOUNTS
Credential:
Phone: 704-522-1550