Provider Demographics
NPI:1801972294
Name:BUSH, STEPHEN RICHARD (DDS)
Entity type:Individual
Prefix:MR
First Name:STEPHEN
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 1:4106 6TH AVE
Mailing Address - Street 2:PO BOX 3198
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68848-3198
Mailing Address - Country:US
Mailing Address - Phone:308-237-3479
Mailing Address - Fax:308-236-9642
Practice Address - Street 1:4106 6TH AVE
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68848-3198
Practice Address - Country:US
Practice Address - Phone:308-237-3479
Practice Address - Fax:308-236-9642
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE5333122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47055213001Medicaid