Provider Demographics
NPI:1801820790
Name:BODE, ROBERT BURTON (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:BURTON
Last Name: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 1:1144 COOLIDGE BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-2622
Mailing Address - Country:US
Mailing Address - Phone:337-234-8788
Mailing Address - Fax:337-234-8723
Practice Address - Street 1:1144 COOLIDGE BLVD STE A
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2622
Practice Address - Country:US
Practice Address - Phone:337-234-8788
Practice Address - Fax:337-234-8723
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA33751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1833754Medicaid