Provider Demographics
NPI:1639299100
Name:KOLODGE, THOMAS A (DDS, MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:A
Last Name:KOLODGE
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1046 NE 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-4418
Mailing Address - Country:US
Mailing Address - Phone:503-472-1468
Mailing Address - Fax:
Practice Address - Street 1:1046 NE 3RD ST
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-4418
Practice Address - Country:US
Practice Address - Phone:503-472-1468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD92721223S0112X
ORMD126317204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery