Provider Demographics
NPI:1518183870
Name:HODGES, BENJAMIN JEMISON (DMD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:JEMISON
Last Name:HODGES
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 BAYOU BLVD STE 3A
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-1905
Mailing Address - Country:US
Mailing Address - Phone:850-478-4260
Mailing Address - Fax:850-478-4618
Practice Address - Street 1:4400 BAYOU BLVD STE 3A
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-1905
Practice Address - Country:US
Practice Address - Phone:850-478-4260
Practice Address - Fax:850-478-4618
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3235-021223G0001X
FLDN194601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08878360Medicaid