Provider Demographics
NPI:1609361047
Name:DODGE, RYAN CLARENCE (DDS)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:CLARENCE
Last Name:DODGE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5837 HARBOUR VIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-2657
Mailing Address - Country:US
Mailing Address - Phone:757-686-3636
Mailing Address - Fax:
Practice Address - Street 1:5837 HARBOUR VIEW BLVD
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-2657
Practice Address - Country:US
Practice Address - Phone:757-686-3636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014161111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice