Provider Demographics
NPI:1235676750
Name:BODNER, PAUL GEREON (DDS)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:GEREON
Last Name:BODNER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 E MAIN ST
Mailing Address - Street 2:SUITE #2
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-2913
Mailing Address - Country:US
Mailing Address - Phone:203-481-2509
Mailing Address - Fax:
Practice Address - Street 1:365 E MAIN ST
Practice Address - Street 2:SUITE #2
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-2913
Practice Address - Country:US
Practice Address - Phone:203-481-2509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-23
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7086122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist