Provider Demographics
NPI:1114038429
Name:BRENT R. BUSH, DDS & KAREN D. BUSH, DDS, PLLC
Entity Type:Organization
Organization Name:BRENT R. BUSH, DDS & KAREN D. BUSH, DDS, PLLC
Other - Org Name:BUSH FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:D
Authorized Official - Last Name:BUSH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:910-313-1511
Mailing Address - Street 1:1717 SHIPYARD BLVD
Mailing Address - Street 2:STE 120
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-8019
Mailing Address - Country:US
Mailing Address - Phone:910-313-1511
Mailing Address - Fax:
Practice Address - Street 1:1717 SHIPYARD BLVD
Practice Address - Street 2:STE 120
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-8019
Practice Address - Country:US
Practice Address - Phone:910-313-1511
Practice Address - Fax:910-313-2520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC68051223G0001X
NC69051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty