Provider Demographics
NPI:1710014063
Name:BUSH, JOHN RICHARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RICHARD
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 1:20 CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02835
Mailing Address - Country:US
Mailing Address - Phone:401-423-2110
Mailing Address - Fax:401-423-9224
Practice Address - Street 1:20 CLINTON AVE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:RI
Practice Address - Zip Code:02835
Practice Address - Country:US
Practice Address - Phone:401-423-2110
Practice Address - Fax:401-423-9224
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI1553122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
80356OtherBLUE CROSS DENTAL
RIJB04157Medicaid