Basic Information
Provider Information | |||||||||
NPI: | 1457575714 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BODZIAK | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DDS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1537 32ND CIR SE | ||||||||
Address2: |   | ||||||||
City: | RIO RANCHO | ||||||||
State: | NM | ||||||||
PostalCode: | 871241967 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5057202019 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | UNM RESIDENCY CLINIC | ||||||||
Address2: | 1801 CAMINO DE SALUD | ||||||||
City: | ALBUQUERQUE | ||||||||
State: | NM | ||||||||
PostalCode: | 87102 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5059254031 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/11/2007 | ||||||||
LastUpdateDate: | 07/05/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 2901017490 | MI | N |   | Dental Providers | Dentist |   | 122300000X | DD2048 | NM | Y |   | Dental Providers | Dentist |   |
ID Information
ID | Type | State | Issuer | Description | 64528766 | 05 | NM |   | MEDICAID |