Provider Demographics
NPI:1578091815
Name:BUSH PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:BUSH PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:BUSH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:334-504-0142
Mailing Address - Street 1:3420 LANSDOWNE DR
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36111-2115
Mailing Address - Country:US
Mailing Address - Phone:334-504-0142
Mailing Address - Fax:
Practice Address - Street 1:4740 WOODMERE BLVD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-3065
Practice Address - Country:US
Practice Address - Phone:334-676-2144
Practice Address - Fax:334-676-2148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-31
Last Update Date:2017-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL62401223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty