Provider Demographics
NPI:1053604041
Name:LOCKE, SHIRLEY KONSTANCE (DDS)
Entity type:Individual
Prefix:DR
First Name:SHIRLEY
Middle Name:KONSTANCE
Last Name:LOCKE
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 1:4429 185TH AVE E
Mailing Address - Street 2:
Mailing Address - City:LAKE TAPPS
Mailing Address - State:WA
Mailing Address - Zip Code:98391-9112
Mailing Address - Country:US
Mailing Address - Phone:253-862-1435
Mailing Address - Fax:
Practice Address - Street 1:4429 185TH AVE E
Practice Address - Street 2:
Practice Address - City:LAKE TAPPS
Practice Address - State:WA
Practice Address - Zip Code:98391-9112
Practice Address - Country:US
Practice Address - Phone:253-862-1435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-24
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE 60491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice