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General NPI Number Information
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NPI Number | 1619101839
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Entity Type | Organization
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Legal Business Name | DWAYNE M. BODIE, DMD, PC
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Dates
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Enumeration Date | 05/04/2009
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Last Update Date | 05/04/2009
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Provider Practice Location Address
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Address Line | 311 N MIDLAND AVE
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City | NYACK
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State | NY
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Zip | 10960-1627
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Country | US
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Telephone | 845-358-5110
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Fax | 845-358-6740
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Provider Business Mailing Address
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Address Line | 311 N MIDLAND AVE
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City | NYACK
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State | NY
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Zip | 10960-1627
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Country | US
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Telephone | 845-358-5110
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Fax | 845-358-6740
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Authorized Official
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Title or Position | CEO/PRESIDENT
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Name | DR. DWAYNE M BODIE
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Credential | D.M.D.
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Telephone | 845-358-5110
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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 | 053605
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License Number State | NY
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