Provider Demographics
NPI:1689457616
Name:BODNAR, MARIYA (DMD)
Entity type:Individual
Prefix:
First Name:MARIYA
Middle Name:
Last Name:BODNAR
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 S COURT ST
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-3960
Mailing Address - Country:US
Mailing Address - Phone:219-266-6550
Mailing Address - Fax:
Practice Address - Street 1:301 S COURT ST
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-3960
Practice Address - Country:US
Practice Address - Phone:219-266-6550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-15
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12014191A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice