Provider Demographics
NPI:1033219712
Name:BUSH, BRADLY ROBERT (DMD)
Entity Type:Individual
Prefix:
First Name:BRADLY
Middle Name:ROBERT
Last Name:BUSH
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 1:1717 BIDDLE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63106-3454
Mailing Address - Country:US
Mailing Address - Phone:314-898-1700
Mailing Address - Fax:314-814-8542
Practice Address - Street 1:1500 PARK AVENUE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-3024
Practice Address - Country:US
Practice Address - Phone:314-898-1700
Practice Address - Fax:314-814-8542
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-23
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019021954122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist