Healthcare Provider Details

I. General information

NPI: 1982693099
Provider Name (Legal Business Name): BRIAN DAVID HODGSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 07/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 W WISCONSIN AVE
MILWAUKEE WI
53233-2186
US

IV. Provider business mailing address

1801 W WISCONSIN AVE
MILWAUKEE WI
53233-2186
US

V. Phone/Fax

Practice location:
  • Phone: 414-288-1566
  • Fax: 414-288-0765
Mailing address:
  • Phone: 414-288-1566
  • Fax: 414-288-0765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019-021052
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number4214-015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: