Provider Demographics
NPI:1346387503
Name:DODGE, KENNETH (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:DODGE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22050 205TH AVE
Mailing Address - Street 2:
Mailing Address - City:LITTLE FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56345-5694
Mailing Address - Country:US
Mailing Address - Phone:320-745-2121
Mailing Address - Fax:320-632-2392
Practice Address - Street 1:1850 1ST AVE NE
Practice Address - Street 2:
Practice Address - City:LITTLE FALLS
Practice Address - State:MN
Practice Address - Zip Code:56345-3381
Practice Address - Country:US
Practice Address - Phone:320-632-2391
Practice Address - Fax:320-632-2392
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2809152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN22-02502OtherMEDICA
MN271L9DOOtherBCBS
MN520042300Medicaid
MN0484240001OtherDMERC
MN169168OtherUCARE
MN931161031064OtherPREFERRED ONE
MN520042300Medicaid