Provider Demographics
NPI:1417951302
Name:DODGE, KENNETH BRENTON (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:BRENTON
Last Name:DODGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4323 CAROTHERS PKWY STE 505
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-5920
Mailing Address - Country:US
Mailing Address - Phone:615-435-7780
Mailing Address - Fax:
Practice Address - Street 1:1950 DOWNS BLVD STE 102
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37064-1562
Practice Address - Country:US
Practice Address - Phone:615-435-7780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000017056207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3021233Medicaid
TN3132242OtherBLUE CROSS BLUE SHIELD
0140590OtherUHC
8822511OtherCIGNA
4295507OtherAETNA
4295507OtherAETNA
A98497Medicare UPIN