Provider Demographics
NPI:1245668508
Name:BODEEN, DUSTIN RICHARD (LAC, LMT)
Entity type:Individual
Prefix:MR
First Name:DUSTIN
Middle Name:RICHARD
Last Name:BODEEN
Suffix:
Gender:M
Credentials:LAC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1836 NE 7TH AVE #206
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212
Mailing Address - Country:US
Mailing Address - Phone:503-282-1070
Mailing Address - Fax:503-282-1990
Practice Address - Street 1:606 120TH AVE NE STE D104
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005-3024
Practice Address - Country:US
Practice Address - Phone:425-455-5444
Practice Address - Fax:425-646-8047
Is Sole Proprietor?:No
Enumeration Date:2013-10-24
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60401348225700000X
OR19300225700000X
ORAC189999171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist