Healthcare Provider Details

I. General information

NPI: 1750146312
Provider Name (Legal Business Name): LAURA BODNAR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2024
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date: 10/03/2024
Reactivation Date: 10/09/2024

III. Provider practice location address

3030 HARBOR BLVD STE G1
COSTA MESA CA
92626-2562
US

IV. Provider business mailing address

9377 MIRAMONTE
IRVINE CA
92618-5615
US

V. Phone/Fax

Practice location:
  • Phone: 714-546-6100
  • Fax:
Mailing address:
  • Phone: 732-877-7539
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number110894
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: