Provider Demographics
NPI:1447131800
Name:DODGE, DANA
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:DODGE
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 1:411 OSPREY CT
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-5851
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:411 OSPREY CT
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-5851
Practice Address - Country:US
Practice Address - Phone:925-548-5440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-10
Last Update Date:2025-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA982181133V00000X
OR982181133V00000X
WA982181133V00000X
CO982181133V00000X
MA982181133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered