Provider Demographics
NPI:1326173634
Name:PEREZ BODE, RENE F (DDS)
Entity Type:Individual
Prefix:
First Name:RENE
Middle Name:F
Last Name:PEREZ BODE
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 1:11 FLEETWOOD TER
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:74227-4443
Mailing Address - Country:US
Mailing Address - Phone:716-632-0114
Mailing Address - Fax:716-632-0114
Practice Address - Street 1:11 FLEETWOOD TER
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:74227-4443
Practice Address - Country:US
Practice Address - Phone:716-632-0114
Practice Address - Fax:716-632-0114
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0284781122300000X
FLDN6102122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00624777Medicaid