Provider Demographics
NPI:1578616140
Name:HODGE, JEFFREY LAURENCE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:LAURENCE
Last Name:HODGE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 N 22ND ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-2601
Mailing Address - Country:US
Mailing Address - Phone:765-447-6733
Mailing Address - Fax:765-447-1552
Practice Address - Street 1:321 N 22ND ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2601
Practice Address - Country:US
Practice Address - Phone:765-447-6733
Practice Address - Fax:765-447-1552
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN86431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice