Provider Demographics
NPI:1700188042
Name:DODSON, ODETTA MARY (LMT)
Entity Type:Individual
Prefix:MS
First Name:ODETTA
Middle Name:MARY
Last Name:DODSON
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 1:4579 SOUTH COBB DR
Mailing Address - Street 2:SUITE 6
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080
Mailing Address - Country:US
Mailing Address - Phone:404-543-0393
Mailing Address - Fax:
Practice Address - Street 1:4579 S COBB DR SE
Practice Address - Street 2:SUITE 600
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-6999
Practice Address - Country:US
Practice Address - Phone:678-838-8333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-18
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000299171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor