Healthcare Provider Details

I. General information

NPI: 1033307434
Provider Name (Legal Business Name): JAMES R HODGE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2007
Last Update Date: 04/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 AVENUE C
FORT PIERCE FL
34950-4189
US

IV. Provider business mailing address

714 AVENUE C
FORT PIERCE FL
34950-4189
US

V. Phone/Fax

Practice location:
  • Phone: 772-462-3827
  • Fax: 772-462-3865
Mailing address:
  • Phone: 772-462-3827
  • Fax: 772-462-3865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN11614
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: