Provider Demographics
NPI:1821057589
Name:DODGION, EARL (DDS)
Entity Type:Individual
Prefix:DR
First Name:EARL
Middle Name:
Last Name:DODGION
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:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:SOUTH FORK
Mailing Address - State:CO
Mailing Address - Zip Code:81154-0247
Mailing Address - Country:US
Mailing Address - Phone:719-873-5846
Mailing Address - Fax:719-873-1516
Practice Address - Street 1:0130 PONDEROSA DRIVE
Practice Address - Street 2:
Practice Address - City:SOUTH FORK
Practice Address - State:CO
Practice Address - Zip Code:81154-0247
Practice Address - Country:US
Practice Address - Phone:719-873-5846
Practice Address - Fax:719-873-1516
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02005924Medicaid