Provider Demographics
NPI:1992119184
Name:BODILY, KEVIN JAMES (DMD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JAMES
Last Name:BODILY
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:PSC 9 BOX 4236
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09123-0043
Mailing Address - Country:US
Mailing Address - Phone:314-452-3510
Mailing Address - Fax:
Practice Address - Street 1:SPANGDAHLEM DENTAL CLINIC
Practice Address - Street 2:SPANGDAHLEM AB, GERMANY
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09123
Practice Address - Country:US
Practice Address - Phone:314-452-3510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-16
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9052001-9921122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist