Provider Demographics
NPI:1114136256
Name:BUSH, DR. P.A.
Entity Type:Organization
Organization Name:BUSH, DR. P.A.
Other - Org Name:PERFECT SMILE DENTAL STUDIO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANA MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-948-6335
Mailing Address - Street 1:24632 STATE ROAD 54
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33559-7307
Mailing Address - Country:US
Mailing Address - Phone:813-948-6335
Mailing Address - Fax:813-948-6394
Practice Address - Street 1:24632 STATE ROAD 54
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33559-7307
Practice Address - Country:US
Practice Address - Phone:813-948-6335
Practice Address - Fax:813-948-6394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN148331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty