Provider Demographics
NPI:1831322668
Name:BUSHMAN, TODD MORONI (DMD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:MORONI
Last Name:BUSHMAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 LAKE AIR DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-4417
Mailing Address - Country:US
Mailing Address - Phone:254-772-8330
Mailing Address - Fax:
Practice Address - Street 1:1121 LAKE AIR DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-4417
Practice Address - Country:US
Practice Address - Phone:254-772-8330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-27
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX249081223P0221X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist