Provider Demographics
NPI:1023037264
Name:BODNAR & WYATT, PLLC
Entity Type:Organization
Organization Name:BODNAR & WYATT, PLLC
Other - Org Name:CATALOOCHEE DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CDPMA
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:S
Authorized Official - Last Name:BENGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-627-1050
Mailing Address - Street 1:103 HAYWOOD PARK DR
Mailing Address - Street 2:
Mailing Address - City:CLYDE
Mailing Address - State:NC
Mailing Address - Zip Code:28721-4405
Mailing Address - Country:US
Mailing Address - Phone:828-627-1050
Mailing Address - Fax:828-627-1056
Practice Address - Street 1:103 HAYWOOD PARK DR
Practice Address - Street 2:
Practice Address - City:CLYDE
Practice Address - State:NC
Practice Address - Zip Code:28721-4405
Practice Address - Country:US
Practice Address - Phone:828-627-1050
Practice Address - Fax:828-627-1056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5902433Medicaid