Provider Demographics
NPI:1861114654
Name:BODWELL, ANDREA (RDH)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:BODWELL
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2926 N WILD ROSE CT
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67205-1638
Mailing Address - Country:US
Mailing Address - Phone:316-640-9049
Mailing Address - Fax:
Practice Address - Street 1:123 N TYLER RD STE 100
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212-3726
Practice Address - Country:US
Practice Address - Phone:316-640-9049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-19
Last Update Date:2024-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11111124Q00000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No124Q00000XDental ProvidersDental Hygienist