Provider Demographics
NPI:1578681235
Name:BUSH, BRADLEY RONALD (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:RONALD
Last Name:BUSH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 649
Mailing Address - Street 2:109 JOHNSON AVE
Mailing Address - City:SCHOHARIE
Mailing Address - State:NY
Mailing Address - Zip Code:12157-0649
Mailing Address - Country:US
Mailing Address - Phone:518-355-3879
Mailing Address - Fax:
Practice Address - Street 1:109 JOHNSON AVENUE
Practice Address - Street 2:
Practice Address - City:SCHOHARIE
Practice Address - State:NY
Practice Address - Zip Code:12157-0649
Practice Address - Country:US
Practice Address - Phone:518-355-3879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047755-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist