Provider Demographics
NPI:1396830493
Name:ROSEBUSH, MARK S (DMD)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:S
Last Name:ROSEBUSH
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 1:2376 MAIN ST STE 812
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59105-4018
Mailing Address - Country:US
Mailing Address - Phone:406-656-5200
Mailing Address - Fax:406-651-0958
Practice Address - Street 1:2376 MAIN ST STE 812
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59105-4018
Practice Address - Country:US
Practice Address - Phone:406-656-5200
Practice Address - Fax:406-651-0958
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT20091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0112421Medicaid
MT20094OtherBLUE CROSS BLUE SHIELD
MT5511468OtherBLUE CHIP AFFILIATED COMP