Provider Demographics
NPI:1053602227
Name:CHARLES LOCKHART DDS
Entity type:Organization
Organization Name:CHARLES LOCKHART DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:D
Authorized Official - Last Name:CRAIG
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:312-676-9893
Mailing Address - Street 1:4748 N MILWAUKEE AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-3617
Mailing Address - Country:US
Mailing Address - Phone:773-685-9339
Mailing Address - Fax:
Practice Address - Street 1:150 E HURON ST
Practice Address - Street 2:SUITE 1103
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2999
Practice Address - Country:US
Practice Address - Phone:312-676-9893
Practice Address - Fax:815-744-7059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-22
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190146181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1457579682OtherTYPE 1 INDIVIDUAL NPI