Provider Demographics
NPI:1891126637
Name:BUSHEY, JOHANNA HEATHER (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHANNA
Middle Name:HEATHER
Last Name:BUSHEY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2217 IVAN ST APT 1415
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75201-7046
Mailing Address - Country:US
Mailing Address - Phone:937-269-8139
Mailing Address - Fax:
Practice Address - Street 1:2517 S BUCKNER BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75227-8501
Practice Address - Country:US
Practice Address - Phone:214-275-0172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-04
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29331122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist