Healthcare Provider Details

I. General information

NPI: 1295184448
Provider Name (Legal Business Name): MATTHEW HODGSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2016
Last Update Date: 06/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 E DOWNING ST
TAHLEQUAH OK
74464-3011
US

IV. Provider business mailing address

312 GOINGSNAKE ST
TAHLEQUAH OK
74464-2910
US

V. Phone/Fax

Practice location:
  • Phone: 918-931-1456
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6821
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: