Provider Demographics
NPI:1336218833
Name:HODGE, JOHN J (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:J
Last Name:HODGE
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4227 POPLAR SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39305-3311
Mailing Address - Country:US
Mailing Address - Phone:601-482-7700
Mailing Address - Fax:601-482-0076
Practice Address - Street 1:4227 POPLAR SPRINGS DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39305-3311
Practice Address - Country:US
Practice Address - Phone:601-482-7700
Practice Address - Fax:601-482-0076
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2731-931223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04529520Medicaid