Active NPI
Jordan Bodily, DMD
- General Practice Dentistry
- Meridian, ID
National Provider Identifier
1356864847
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- D-5115
- Practice address
- 1558 N Crestmont Dr
Meridian, ID 83642-2192 - Phone
- (208) 519-3474
- NPI assigned
- Jul 17, 2017
- Last updated
- Mar 12, 2024
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | D-5115 | ID | Primary |
Addresses
Primary practice location
1558 N Crestmont Dr
Meridian, ID 83642-2192
Mailing address
1558 N Crestmont Dr
Meridian, ID 83642-2192
Phone (208) 519-3474
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| D-5115 | ID | MD | General Practice Dentistry |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1500249600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1710201600000",
"number": "1356864847",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1558 N CRESTMONT DR",
"city": "MERIDIAN",
"state": "ID",
"postal_code": "836422192",
"telephone_number": "208-519-3474"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1558 N CRESTMONT DR",
"city": "MERIDIAN",
"state": "ID",
"postal_code": "836422192",
"telephone_number": "208-519-3474"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BODILY",
"first_name": "JORDAN",
"credential": "DMD",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2017-07-17",
"last_updated": "2024-03-12",
"certification_date": "2024-03-12",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "ID",
"license": "D-5115",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Meridian, ID
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 12, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.