Provider Demographics
NPI:1841738200
Name:HODSON, SHANE PHILIP (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:PHILIP
Last Name:HODSON
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 1:3000 ISLAND BLVD
Mailing Address - Street 2:APT 1402
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33160-4923
Mailing Address - Country:US
Mailing Address - Phone:305-725-8907
Mailing Address - Fax:
Practice Address - Street 1:18333 NE 19TH AVE
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33179-5031
Practice Address - Country:US
Practice Address - Phone:305-725-8907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-06
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL217101223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics