Provider Demographics
NPI:1013069491
Name:BUSH, MICHAEL B (DDS)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:B
Last Name:BUSH
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 1:3221 BARLOW CT
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28409-2583
Mailing Address - Country:US
Mailing Address - Phone:910-398-0224
Mailing Address - Fax:
Practice Address - Street 1:7864 US HIGHWAY 117
Practice Address - Street 2:SUITE A
Practice Address - City:ROCKY POINT
Practice Address - State:NC
Practice Address - Zip Code:28457
Practice Address - Country:US
Practice Address - Phone:910-210-2058
Practice Address - Fax:910-210-2065
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC82701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5904628Medicaid