Provider Demographics
NPI:1639482359
Name:DODGE, MOLLY (LMT)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:DODGE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16110 NW CENTINE LN
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-1130
Mailing Address - Country:US
Mailing Address - Phone:503-575-6544
Mailing Address - Fax:503-466-1143
Practice Address - Street 1:16110 NW CENTINE LN
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-1130
Practice Address - Country:US
Practice Address - Phone:503-575-6544
Practice Address - Fax:503-466-1143
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-22
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12655174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist