Provider Demographics
NPI:1255444154
Name:BODIE, DAVID JACKSON (DDS)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JACKSON
Last Name:BODIE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 N FLOYD RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-4242
Mailing Address - Country:US
Mailing Address - Phone:972-235-4767
Mailing Address - Fax:972-479-0566
Practice Address - Street 1:1111 N FLOYD RD
Practice Address - Street 2:SUITE B
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-4242
Practice Address - Country:US
Practice Address - Phone:972-235-4767
Practice Address - Fax:972-479-0566
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX129371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice