Provider Demographics
NPI:1750469441
Name:HODGKIN, KEITH WAYNE (DDS)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:WAYNE
Last Name:HODGKIN
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 1:5218 STOCKTON HILL RD
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-1042
Mailing Address - Country:US
Mailing Address - Phone:928-692-2212
Mailing Address - Fax:928-692-5807
Practice Address - Street 1:5218 STOCKTON HILL RD
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-1042
Practice Address - Country:US
Practice Address - Phone:928-692-2212
Practice Address - Fax:928-692-5807
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ64181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice