Healthcare Provider Details

I. General information

NPI: 1306200167
Provider Name (Legal Business Name): MOLLY BODENDORFER DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2016
Last Update Date: 10/13/2023
Certification Date: 10/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2410 S 73RD ST
OMAHA NE
68124-2395
US

IV. Provider business mailing address

365 N HALSTED ST APT 902
CHICAGO IL
60661-1374
US

V. Phone/Fax

Practice location:
  • Phone: 402-819-4977
  • Fax:
Mailing address:
  • Phone: 316-655-3731
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number021.003036
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number7768
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: