Provider Demographics
NPI:1811401441
Name:BUSHNELL, JACOB KENNETH (DDS)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:KENNETH
Last Name:BUSHNELL
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 1:1414 MARINE DR
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-3808
Mailing Address - Country:US
Mailing Address - Phone:503-325-0310
Mailing Address - Fax:503-325-1513
Practice Address - Street 1:1414 MARINE DR
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-3808
Practice Address - Country:US
Practice Address - Phone:503-325-0310
Practice Address - Fax:503-325-1513
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-17
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD107271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice