Provider Demographics
NPI:1518131200
Name:BUSSICK, TIMOTHY JAY (DDS; MS)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JAY
Last Name:BUSSICK
Suffix:
Gender:M
Credentials:DDS; MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7207 ENGLE RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-2231
Mailing Address - Country:US
Mailing Address - Phone:260-436-2255
Mailing Address - Fax:260-432-5466
Practice Address - Street 1:7207 ENGLE RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-2231
Practice Address - Country:US
Practice Address - Phone:260-436-2255
Practice Address - Fax:260-432-5466
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009656A1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics