Provider Demographics
NPI:1194891242
Name:HODGE, JEREMY L (DMD)
Entity type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:L
Last Name:HODGE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9012 MATHIS AVE
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-5218
Mailing Address - Country:US
Mailing Address - Phone:571-912-1111
Mailing Address - Fax:571-921-1112
Practice Address - Street 1:9012 MATHIS AVE
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-5218
Practice Address - Country:US
Practice Address - Phone:571-912-1111
Practice Address - Fax:571-921-1112
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101413727122300000X
IDD38081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA806913500OtherDENTAQUEST
6K216OtherBLUE CROSS