Healthcare Provider Details

I. General information

NPI: 1053964445
Provider Name (Legal Business Name): LAUREN HODGE JAIN DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAUREN MICHELLE HODGE DMD

II. Dates (important events)

Enumeration Date: 07/24/2019
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 TEACO RD
KENNETT MO
63857-3236
US

IV. Provider business mailing address

215 TEACO RD
KENNETT MO
63857-3236
US

V. Phone/Fax

Practice location:
  • Phone: 573-888-5936
  • Fax:
Mailing address:
  • Phone: 573-888-5936
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number11092
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number4379
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2020012234
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: