Provider Demographics
NPI:1972725141
Name:BODEN, BRETT D (DMD)
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:D
Last Name:BODEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:564 W UWCHLAN AVE
Mailing Address - Street 2:
Mailing Address - City:EXTON
Mailing Address - State:PA
Mailing Address - Zip Code:19341-1562
Mailing Address - Country:US
Mailing Address - Phone:610-363-7658
Mailing Address - Fax:610-524-6839
Practice Address - Street 1:564 W UWCHLAN AVE
Practice Address - Street 2:
Practice Address - City:EXTON
Practice Address - State:PA
Practice Address - Zip Code:19341-1562
Practice Address - Country:US
Practice Address - Phone:610-363-7658
Practice Address - Fax:610-524-6839
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA15592122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist