Provider Demographics
NPI:1962806299
Name:DODD-MARTINSON, MARY LOUISE
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LOUISE
Last Name:DODD-MARTINSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-2663
Mailing Address - Country:US
Mailing Address - Phone:541-993-5172
Mailing Address - Fax:
Practice Address - Street 1:700 E 10TH ST
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-2663
Practice Address - Country:US
Practice Address - Phone:541-993-5172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-15
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH2876124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist