Provider Demographics
NPI:1336240290
Name:BUSH, JOHN RICHARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RICHARD
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 1:110 RIDING TRL
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-9165
Mailing Address - Country:US
Mailing Address - Phone:704-662-6907
Mailing Address - Fax:
Practice Address - Street 1:8401 UNIVERSITY EXECUTIVE DR
Practice Address - Street 2:SUITE 110
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-3386
Practice Address - Country:US
Practice Address - Phone:704-547-1970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8075122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist