Provider Demographics
NPI:1194743948
Name:DODGE, BRENT ALAN (PT)
Entity type:Individual
Prefix:MR
First Name:BRENT
Middle Name:ALAN
Last Name:DODGE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 BLUE MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-9207
Mailing Address - Country:US
Mailing Address - Phone:406-251-2323
Mailing Address - Fax:406-251-2999
Practice Address - Street 1:5000 BLUE MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-9207
Practice Address - Country:US
Practice Address - Phone:406-251-2323
Practice Address - Fax:406-251-2999
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT709225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000050890Medicare PIN