Provider Demographics
NPI:1780467258
Name:HODGE, KENTON DONELLE (LDO)
Entity type:Individual
Prefix:
First Name:KENTON
Middle Name:DONELLE
Last Name:HODGE
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7204 BRIGHTON CT
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-8239
Mailing Address - Country:US
Mailing Address - Phone:229-400-6457
Mailing Address - Fax:
Practice Address - Street 1:1940 MOUNTAIN INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-6619
Practice Address - Country:US
Practice Address - Phone:678-280-0248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1946156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician