Provider Demographics
NPI:1861464687
Name:HODGE, WESLEY MARK (DMD)
Entity Type:Individual
Prefix:DR
First Name:WESLEY
Middle Name:MARK
Last Name:HODGE
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 1:8701 S GARNETT
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012
Mailing Address - Country:US
Mailing Address - Phone:918-250-9520
Mailing Address - Fax:918-250-9529
Practice Address - Street 1:8701 S GARNETT
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012
Practice Address - Country:US
Practice Address - Phone:918-250-9520
Practice Address - Fax:918-250-9529
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK46601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice