Provider Demographics
NPI:1336170026
Name:DODGE, JEFFREY EDWARD I (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:EDWARD
Last Name:DODGE
Suffix:I
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1438 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895-6557
Mailing Address - Country:US
Mailing Address - Phone:401-762-3044
Mailing Address - Fax:401-769-0603
Practice Address - Street 1:1438 PARK AVE
Practice Address - Street 2:
Practice Address - City:WOONSOCKET
Practice Address - State:RI
Practice Address - Zip Code:02895-6557
Practice Address - Country:US
Practice Address - Phone:401-762-3044
Practice Address - Fax:401-769-0603
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI22271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI8041-3OtherBC/BS DENTAL RI & MA
RIJD01450Medicaid