Provider Demographics
NPI:1124836770
Name:BODMAN, CALVIN CHASE (DDS)
Entity type:Individual
Prefix:
First Name:CALVIN
Middle Name:CHASE
Last Name:BODMAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:538 SONOMA ST
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-4238
Mailing Address - Country:US
Mailing Address - Phone:760-978-7085
Mailing Address - Fax:
Practice Address - Street 1:4900 WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-3115
Practice Address - Country:US
Practice Address - Phone:323-780-0009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-27
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA111114122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist