Provider Demographics
NPI:1083779144
Name:LODGE, PETER J (DMD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:J
Last Name:LODGE
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 1:28 CASWELL ST
Mailing Address - Street 2:
Mailing Address - City:NARRAGANSETT
Mailing Address - State:RI
Mailing Address - Zip Code:02882-3385
Mailing Address - Country:US
Mailing Address - Phone:401-789-3010
Mailing Address - Fax:401-789-5159
Practice Address - Street 1:28 CASWELL ST
Practice Address - Street 2:
Practice Address - City:NARRAGANSETT
Practice Address - State:RI
Practice Address - Zip Code:02882-3385
Practice Address - Country:US
Practice Address - Phone:401-789-3010
Practice Address - Fax:401-789-5159
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI16521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice