Provider Demographics
NPI:1295809754
Name:DODGE, LORI (LMP)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:DODGE
Suffix:
Gender:F
Credentials:LMP
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 2501
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-0325
Mailing Address - Country:US
Mailing Address - Phone:360-509-5800
Mailing Address - Fax:360-876-6083
Practice Address - Street 1:1736 NE RIDDELL RD STE 103
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-3685
Practice Address - Country:US
Practice Address - Phone:360-509-5800
Practice Address - Fax:360-876-6083
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00015829174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist