Provider Demographics
NPI:1821091778
Name:BUSSARD, DAVID A (DDS, MS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:BUSSARD
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10972 ALLISONVILLE RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-2637
Mailing Address - Country:US
Mailing Address - Phone:317-845-7878
Mailing Address - Fax:317-570-7193
Practice Address - Street 1:10972 ALLISONVILLE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038-2637
Practice Address - Country:US
Practice Address - Phone:317-845-7878
Practice Address - Fax:317-570-7193
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007454A1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100335980Medicaid
IN268030AMedicare ID - Type Unspecified
IN100335980Medicaid