Provider Demographics
NPI:1801820725
Name:BUSH, JEAN HELEN
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:HELEN
Last Name:BUSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 E LOHMAN, STE 121
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001
Mailing Address - Country:US
Mailing Address - Phone:505-526-4334
Mailing Address - Fax:505-526-7863
Practice Address - Street 1:2001 E LOHMAN, STE 121
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001
Practice Address - Country:US
Practice Address - Phone:505-526-4334
Practice Address - Fax:505-526-7863
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA425611223G0001X
NMDD29011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice