Provider Demographics
NPI:1043340268
Name:BUSH, MARK E (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:BUSH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4112 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68845-3395
Mailing Address - Country:US
Mailing Address - Phone:308-236-9694
Mailing Address - Fax:308-237-4414
Practice Address - Street 1:4112 6TH AVE
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68845-3395
Practice Address - Country:US
Practice Address - Phone:308-236-9694
Practice Address - Fax:308-237-4414
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE5425122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47-0696645-12Medicaid