Provider Demographics
NPI:1720387434
Name:BOUSHEE, BRANDI LEA (RDH)
Entity Type:Individual
Prefix:MISS
First Name:BRANDI
Middle Name:LEA
Last Name:BOUSHEE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1599 J ST BLDG 109A
Mailing Address - Street 2:
Mailing Address - City:GFAFB
Mailing Address - State:ND
Mailing Address - Zip Code:58205-6306
Mailing Address - Country:US
Mailing Address - Phone:701-747-5393
Mailing Address - Fax:
Practice Address - Street 1:1599 J ST BLDG 109A
Practice Address - Street 2:
Practice Address - City:GFAFB
Practice Address - State:ND
Practice Address - Zip Code:58205-6306
Practice Address - Country:US
Practice Address - Phone:701-747-5393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-21
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1160124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist