Provider Demographics
NPI:1033109061
Name:BODIN, ROBERT LUTHER
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:LUTHER
Last Name:BODIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 FRANCE AVE S
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-1805
Mailing Address - Country:US
Mailing Address - Phone:952-224-9783
Mailing Address - Fax:
Practice Address - Street 1:5100 EDEN AVE
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55436-2337
Practice Address - Country:US
Practice Address - Phone:952-929-0641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND71721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice