Provider Demographics
NPI:1457575714
Name:BODZIAK, JENNIFER (DDS)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:BODZIAK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1537 32ND CIR SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1967
Mailing Address - Country:US
Mailing Address - Phone:505-720-2019
Mailing Address - Fax:
Practice Address - Street 1:UNM RESIDENCY CLINIC
Practice Address - Street 2:1801 CAMINO DE SALUD
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102
Practice Address - Country:US
Practice Address - Phone:505-925-4031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901017490122300000X
NMDD2048122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM64528766Medicaid