Provider Demographics
NPI:1255676524
Name:BUSH, CHAD A (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:A
Last Name:BUSH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 US HIGHWAY 19 S
Mailing Address - Street 2:P.O. BOX 681
Mailing Address - City:LEESBURG
Mailing Address - State:GA
Mailing Address - Zip Code:31763-4880
Mailing Address - Country:US
Mailing Address - Phone:229-888-3550
Mailing Address - Fax:229-317-3569
Practice Address - Street 1:919 US HIGHWAY 19 S
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:GA
Practice Address - Zip Code:31763-4880
Practice Address - Country:US
Practice Address - Phone:229-888-3550
Practice Address - Fax:229-317-3569
Is Sole Proprietor?:No
Enumeration Date:2012-11-28
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA011237122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist