Provider Demographics
NPI:1205554995
Name:BUSH, DERRICK JAMES (DMD)
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:JAMES
Last Name:BUSH
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 1:6524 CORONADO CANYON AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89142-2878
Mailing Address - Country:US
Mailing Address - Phone:702-376-9455
Mailing Address - Fax:
Practice Address - Street 1:4 SUNSET WAY
Practice Address - Street 2:UNIT C
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014
Practice Address - Country:US
Practice Address - Phone:702-376-9455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-18
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV76461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice