Provider Demographics
NPI:1033464938
Name:BUSHMAN, JACK C (DMD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:C
Last Name:BUSHMAN
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 1:3150 ZELDA CT
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-2607
Mailing Address - Country:US
Mailing Address - Phone:334-281-2451
Mailing Address - Fax:334-281-1087
Practice Address - Street 1:3150 ZELDA CT
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-2607
Practice Address - Country:US
Practice Address - Phone:334-281-2451
Practice Address - Fax:334-281-1087
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL59311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice