Provider Demographics
NPI:1942587340
Name:HODGE, JAMES WALTER (DDS)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:WALTER
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:PO BOX 2273
Mailing Address - Street 2:
Mailing Address - City:KETCHUM
Mailing Address - State:ID
Mailing Address - Zip Code:83340-2273
Mailing Address - Country:US
Mailing Address - Phone:208-726-2233
Mailing Address - Fax:
Practice Address - Street 1:620 1ST AVENUE NORTH
Practice Address - Street 2:
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340-2273
Practice Address - Country:US
Practice Address - Phone:208-726-2233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-14
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-20231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice