Provider Demographics
NPI:1467669762
Name:BUSCH, ROBERT JOHN (DMD MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JOHN
Last Name:BUSCH
Suffix:
Gender:M
Credentials:DMD MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2807 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-2869
Mailing Address - Country:US
Mailing Address - Phone:309-682-1213
Mailing Address - Fax:309-682-1213
Practice Address - Street 1:2807 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-2869
Practice Address - Country:US
Practice Address - Phone:309-682-1213
Practice Address - Fax:309-682-1213
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX00219341223S0112X
TXBP10028831390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX177585009Medicaid
TX1467669762OtherBLUE CROSS BLUE SHIELD
TX177585010Medicaid
TX21934OtherTX DENTAL
TXBP10028831OtherPHYSICIAN IN TRAINING
TX21934OtherTX DENTAL