Healthcare Provider Details

I. General information

NPI: 1679634109
Provider Name (Legal Business Name): HODOSH DENTAL ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 05/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

243 ELMWOOD AVE
PROVIDENCE RI
02907-1547
US

IV. Provider business mailing address

243 ELMWOOD AVE
PROVIDENCE RI
02907-1547
US

V. Phone/Fax

Practice location:
  • Phone: 401-467-4600
  • Fax: 401-781-9854
Mailing address:
  • Phone: 401-467-4600
  • Fax: 401-781-9854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number1854
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2280
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1854
License Number StateRI
# 4
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number2280
License Number StateRI
# 5
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number2280
License Number StateRI
# 6
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2280
License Number StateRI
# 7
Primary TaxonomyN
Taxonomy Code122400000X
TaxonomyDenturist
License Number2280
License Number StateRI
# 8
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number2280
License Number StateRI

VIII. Authorized Official

Name: DR. ALEX HODOSH
Title or Position: DR. -MANAGER
Credential: DMD
Phone: 401-467-4600