Provider Demographics
NPI:1649390766
Name:BUSH II, LARRY A (DDS)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:A
Last Name:BUSH II
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 1:1543 N ELMS RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-2034
Mailing Address - Country:US
Mailing Address - Phone:810-230-8477
Mailing Address - Fax:810-230-8479
Practice Address - Street 1:1543 N ELMS RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-2034
Practice Address - Country:US
Practice Address - Phone:810-230-8477
Practice Address - Fax:810-230-8479
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010195041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice