MEDICARE: NORTHEAST TEXAS PERIODONTAL SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0300X	Periodontics	20061	TX

General Provider Information

NPI Number	:	1912293853
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHEAST TEXAS PERIODONTAL SERVICES

Provider Business Mailing Address
First Line	:	PO BOX 6578
Second Line	:
City	:	PARIS
State	:	TX
Zip	:	75461-6578
Country	:	US
Telephone Number	:	903-785-4832
Fax Number	:

Provider Business Practice Location Address
First Line	:	3420 CLARKSVILLE ST
Second Line	:
City	:	PARIS
State	:	TX
Zip	:	75460-8014
Country	:	US
Telephone Number	:	903-785-4832
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. NATHAN E HODGES
Credential	:	D.D.S., M.S.
Telephone Number	:	903-785-4832

Provider Enumeration Date	:	06/20/2011
Last Update Date	:	06/20/2011

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Directions to “NORTHEAST TEXAS PERIODONTAL SERVICES ” Practice Location

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