Basic Information
| Provider Information | |||||||||
| NPI: | 1639482359 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DODGE | ||||||||
| FirstName: | MOLLY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 16110 NW CENTINE LN | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972291130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035756544 | ||||||||
| FaxNumber: | 5034661143 | ||||||||
| Practice Location | |||||||||
| Address1: | 16110 NW CENTINE LN | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972291130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035756544 | ||||||||
| FaxNumber: | 5034661143 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2010 | ||||||||
| LastUpdateDate: | 07/22/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 12655 | OR | Y | Other Service Providers | Specialist |
No ID Information.