Provider Demographics
NPI:1235260639
Name:BODDEN, KIMBERLY EASLEY (DDS)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:EASLEY
Last Name:BODDEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 S SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70403-4136
Mailing Address - Country:US
Mailing Address - Phone:985-542-1997
Mailing Address - Fax:
Practice Address - Street 1:104 S SPRUCE ST
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-4136
Practice Address - Country:US
Practice Address - Phone:985-542-1997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2009-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA55611223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1855618Medicaid