Provider Demographics
NPI:1669406203
Name:HODGE, OLIVER LEE II
Entity type:Individual
Prefix:DR
First Name:OLIVER
Middle Name:LEE
Last Name:HODGE
Suffix:II
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:OLIVER
Other - Middle Name:LEE
Other - Last Name:HODGE
Other - Suffix:II
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:235 WESTLAKE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-4863
Mailing Address - Country:US
Mailing Address - Phone:910-483-0409
Mailing Address - Fax:910-426-2749
Practice Address - Street 1:235 WESTLAKE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314-4863
Practice Address - Country:US
Practice Address - Phone:910-483-0409
Practice Address - Fax:910-426-2749
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5995122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1669406203Medicaid