Provider Demographics
NPI:1952681090
Name:DODGE, THOMAS DAVID
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:DAVID
Last Name:DODGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15242 N HOLLY RD
Mailing Address - Street 2:
Mailing Address - City:HOLLY
Mailing Address - State:MI
Mailing Address - Zip Code:48442-1141
Mailing Address - Country:US
Mailing Address - Phone:248-634-2314
Mailing Address - Fax:248-634-0998
Practice Address - Street 1:15242 N HOLLY RD
Practice Address - Street 2:
Practice Address - City:HOLLY
Practice Address - State:MI
Practice Address - Zip Code:48442-1141
Practice Address - Country:US
Practice Address - Phone:248-634-2314
Practice Address - Fax:248-634-0998
Is Sole Proprietor?:No
Enumeration Date:2011-08-21
Last Update Date:2011-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302020473183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist