Healthcare Provider Details

I. General information

NPI: 1457575714
Provider Name (Legal Business Name): JENNIFER BODZIAK DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 07/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNM RESIDENCY CLINIC 1801 CAMINO DE SALUD
ALBUQUERQUE NM
87102
US

IV. Provider business mailing address

1537 32ND CIR SE
RIO RANCHO NM
87124-1967
US

V. Phone/Fax

Practice location:
  • Phone: 505-925-4031
  • Fax:
Mailing address:
  • Phone: 505-720-2019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2901017490
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD2048
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: