Provider Demographics
NPI:1750146312
Name:BODNAR, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BODNAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9377 MIRAMONTE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-5615
Mailing Address - Country:US
Mailing Address - Phone:732-877-7539
Mailing Address - Fax:
Practice Address - Street 1:3030 HARBOR BLVD STE G1
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-2562
Practice Address - Country:US
Practice Address - Phone:714-546-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-13
Last Update Date:2024-10-09
Deactivation Date:2024-10-03
Deactivation Code:
Reactivation Date:2024-10-09
Provider Licenses
StateLicense IDTaxonomies
MA390200000X
390200000X
CA110894122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program