Provider Demographics
NPI:1467028969
Name:PARKDALE DENTAL CENTER LLC
Entity Type:Organization
Organization Name:PARKDALE DENTAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AARON
Authorized Official - Middle Name:J
Authorized Official - Last Name:BUSHONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-573-3546
Mailing Address - Street 1:5764 WINDY DR
Mailing Address - Street 2:
Mailing Address - City:STEVENS POINT
Mailing Address - State:WI
Mailing Address - Zip Code:54482-8486
Mailing Address - Country:US
Mailing Address - Phone:715-341-2220
Mailing Address - Fax:
Practice Address - Street 1:5764 WINDY DR
Practice Address - Street 2:
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54482-8486
Practice Address - Country:US
Practice Address - Phone:715-341-2220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-03
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty