Provider Demographics
NPI:1578653614
Name:BUSCH, LOWELL G
Entity Type:Individual
Prefix:DR
First Name:LOWELL
Middle Name:G
Last Name:BUSCH
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 1:2495 SHREVEPORT HWY
Mailing Address - Street 2:PO BOX 69004
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71306-9004
Mailing Address - Country:US
Mailing Address - Phone:318-473-0010
Mailing Address - Fax:318-483-5168
Practice Address - Street 1:2495 SHREVEPORT HWY
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71306-9004
Practice Address - Country:US
Practice Address - Phone:318-473-0010
Practice Address - Fax:318-483-5168
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0118541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice