Provider Demographics
NPI:1215556741
Name:BUSSARD, JOSHUA
Entity Type:Individual
Prefix:DR
First Name:JOSHUA
Middle Name:
Last Name:BUSSARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3785 CARPENTER RD
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-9809
Mailing Address - Country:US
Mailing Address - Phone:734-272-4527
Mailing Address - Fax:
Practice Address - Street 1:3785 CARPENTER RD
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-9809
Practice Address - Country:US
Practice Address - Phone:734-272-4527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-14
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013573A122300000X
HI390200000X
MI29016011931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program