Provider Demographics
NPI:1912293853
Name:NORTHEAST TEXAS PERIODONTAL SERVICES
Entity Type:Organization
Organization Name:NORTHEAST TEXAS PERIODONTAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:HODGES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:903-785-4832
Mailing Address - Street 1:PO BOX 6578
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:TX
Mailing Address - Zip Code:75461-6578
Mailing Address - Country:US
Mailing Address - Phone:903-785-4832
Mailing Address - Fax:
Practice Address - Street 1:3420 CLARKSVILLE ST
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TX
Practice Address - Zip Code:75460-8014
Practice Address - Country:US
Practice Address - Phone:903-785-4832
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX200611223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty