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General NPI Number Information
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NPI Number | 1356864847
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Entity Type | Individual
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Provider Name | JORDAN BODILY DMD
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Gender | Female
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Dates
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Enumeration Date | 07/17/2017
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Last Update Date | 03/12/2024
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Provider Practice Location Address
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Address Line | 1558 N CRESTMONT DR
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City | MERIDIAN
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State | ID
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Zip | 83642-2192
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Country | US
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Telephone | 208-519-3474
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Fax |
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Provider Business Mailing Address
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Address Line | 1558 N CRESTMONT DR
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City | MERIDIAN
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State | ID
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Zip | 83642-2192
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Country | US
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Telephone | 208-519-3474
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D-5115
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License Number State | ID
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