=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417305376
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STEVEN C LOCKETT DMD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2016
-----------------------------------------------------
Last Update Date | 06/01/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14300 SE PETROVITSKY RD
-----------------------------------------------------
City | RENTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98058-8955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-226-2348
-----------------------------------------------------
Fax | 425-226-2392
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14300 SE PETROVITSKY RD
-----------------------------------------------------
City | RENTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98058-8955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-226-2348
-----------------------------------------------------
Fax | 425-226-2392
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | OONA DAVIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 425-226-2348
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 5589
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------