Provider Demographics
NPI:1336288455
Name:BUSHNELL, BENJAMIN DAVID
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:DAVID
Last Name:BUSHNELL
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:PO BOX 302
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:MT
Mailing Address - Zip Code:59922
Mailing Address - Country:US
Mailing Address - Phone:406-844-3825
Mailing Address - Fax:406-844-3972
Practice Address - Street 1:150 BILLS RD
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:MT
Practice Address - Zip Code:59922
Practice Address - Country:US
Practice Address - Phone:406-844-3825
Practice Address - Fax:406-844-3972
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT2127122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0113458Medicaid