Provider Demographics
NPI:1134103211
Name:BUSH, LOUIS R (DDS)
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:R
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 1:2001 CENTRO FAMILIAR BLVD SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87105-4592
Mailing Address - Country:US
Mailing Address - Phone:505-873-7405
Mailing Address - Fax:
Practice Address - Street 1:8 MEDICAL CENTER RD
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:NM
Practice Address - Zip Code:87015-7086
Practice Address - Country:US
Practice Address - Phone:505-873-7405
Practice Address - Fax:505-873-7444
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-02
Last Update Date:2009-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD2580122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist