Provider Demographics
NPI:1427129782
Name:BODILY, DANIEL REED II (MDM)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:REED
Last Name:BODILY
Suffix:II
Gender:M
Credentials:MDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 N 8TH ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-4218
Mailing Address - Country:US
Mailing Address - Phone:208-342-6549
Mailing Address - Fax:208-336-6760
Practice Address - Street 1:1003 N 8TH ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4218
Practice Address - Country:US
Practice Address - Phone:208-342-6549
Practice Address - Fax:208-336-6760
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3109122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist