Healthcare Provider Details

I. General information

NPI: 1912432790
Provider Name (Legal Business Name): NOLAN BODAH D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2017
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2029 STONECROP DR
WILMINGTON NC
28412-0108
US

IV. Provider business mailing address

10 JASMINE PL
WRIGHTSVILLE BEACH NC
28480-1958
US

V. Phone/Fax

Practice location:
  • Phone: 910-218-8858
  • Fax:
Mailing address:
  • Phone: 315-408-8666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number10956
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: