Healthcare Provider Details

I. General information

NPI: 1992119184
Provider Name (Legal Business Name): KEVIN JAMES BODILY D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2014
Last Update Date: 08/21/2025
Certification Date: 08/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SPANGDAHLEM DENTAL CLINIC SPANGDAHLEM AB, GERMANY
APO AE
09123
US

IV. Provider business mailing address

7321 BALMER ST BLDG 570
HILL AFB UT
84056-5012
US

V. Phone/Fax

Practice location:
  • Phone: 314-452-3510
  • Fax:
Mailing address:
  • Phone: 801-777-7011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD010255
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number9052001-9926
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: