Provider Demographics
NPI:1780930008
Name:BUSHUE, BAILEY RENEE
Entity type:Individual
Prefix:
First Name:BAILEY
Middle Name:RENEE
Last Name:BUSHUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BAILEY
Other - Middle Name:RENEE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:470 SHAFER LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97530-9694
Mailing Address - Country:US
Mailing Address - Phone:541-306-8019
Mailing Address - Fax:
Practice Address - Street 1:1314 NE GRAND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1127
Practice Address - Country:US
Practice Address - Phone:503-286-6868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-24
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH5790124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist