Provider Demographics
NPI:1043592397
Name:WILLIAM J BUSACCA DDS, PS
Entity Type:Organization
Organization Name:WILLIAM J BUSACCA DDS, PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LEAH
Authorized Official - Middle Name:R
Authorized Official - Last Name:HENDRICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-426-9711
Mailing Address - Street 1:1525 OLYMPIC HWY N
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-3049
Mailing Address - Country:US
Mailing Address - Phone:360-426-9711
Mailing Address - Fax:360-426-6361
Practice Address - Street 1:1525 OLYMPIC HWY N
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-3049
Practice Address - Country:US
Practice Address - Phone:360-426-9711
Practice Address - Fax:360-426-6361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-13
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA42751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty