Provider Demographics
NPI:1972941094
Name:BOGDAN N BODROUG, DDS, PS
Entity type:Organization
Organization Name:BOGDAN N BODROUG, DDS, PS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JILLIAN
Authorized Official - Middle Name:N
Authorized Official - Last Name:GOOD-BODROUG
Authorized Official - Suffix:
Authorized Official - Credentials:RDA
Authorized Official - Phone:503-490-1275
Mailing Address - Street 1:2701 NE 114TH AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-4289
Mailing Address - Country:US
Mailing Address - Phone:503-427-2984
Mailing Address - Fax:
Practice Address - Street 1:2701 NE 114TH AVE
Practice Address - Street 2:SUITE 6
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-4289
Practice Address - Country:US
Practice Address - Phone:503-427-2984
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-11
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00010445122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2001307Medicaid