Provider Demographics
NPI:1356864847
Name:BODILY, JORDAN (DMD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:BODILY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1558 N CRESTMONT DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-2192
Mailing Address - Country:US
Mailing Address - Phone:208-519-3474
Mailing Address - Fax:
Practice Address - Street 1:1558 N CRESTMONT DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2192
Practice Address - Country:US
Practice Address - Phone:208-519-3474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-17
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-51151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice