MEDICARE: DONALD DODGE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	039774-1	NY

General Provider Information

NPI Number	:	1245362243
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONALD DODGE

Provider Business Mailing Address
First Line	:	14 BUNNY LN
Second Line	:
City	:	EAST SETAUKET
State	:	NY
Zip	:	11733-3504
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	492 OLD TOWN RD
Second Line	:
City	:	PORT JEFFERSON STATION
State	:	NY
Zip	:	11776-2249
Country	:	US
Telephone Number	:	631-928-1018
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/12/2007
Last Update Date	:	07/08/2007

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