Provider Demographics
NPI:1205572245
Name:BRUSH, JAKE DOUGLAS (DDS)
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:DOUGLAS
Last Name:BRUSH
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 1:1695 LIEBCHEN CT
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47025-9067
Mailing Address - Country:US
Mailing Address - Phone:513-532-5923
Mailing Address - Fax:
Practice Address - Street 1:310 W LOSEY ST
Practice Address - Street 2:
Practice Address - City:SCOTT AFB
Practice Address - State:IL
Practice Address - Zip Code:62225-5250
Practice Address - Country:US
Practice Address - Phone:618-256-2833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-11
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1205572245122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist