Provider Demographics
NPI:1366944290
Name:BODTORF, BREANNA NICHOLE (RDH)
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:NICHOLE
Last Name:BODTORF
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:BREANNA
Other - Middle Name:NICHOLE
Other - Last Name:CLINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:100 SHENANGO AVE
Mailing Address - Street 2:
Mailing Address - City:SHARON
Mailing Address - State:PA
Mailing Address - Zip Code:16146-1503
Mailing Address - Country:US
Mailing Address - Phone:717-248-9900
Mailing Address - Fax:717-248-9910
Practice Address - Street 1:106 DERRY HEIGHTS BLVD
Practice Address - Street 2:
Practice Address - City:LEWISTOWN
Practice Address - State:PA
Practice Address - Zip Code:17044-8604
Practice Address - Country:US
Practice Address - Phone:717-248-9900
Practice Address - Fax:717-248-9910
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-07
Last Update Date:2025-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADH073123124Q00000X
PAPHDH001234124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist