1114038429 NPI number — BRENT R. BUSH, DDS & KAREN D. BUSH, DDS, PLLC

Table of content: (NPI 1114038429)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114038429 NPI number — BRENT R. BUSH, DDS & KAREN D. BUSH, DDS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRENT R. BUSH, DDS & KAREN D. BUSH, DDS, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114038429
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/06/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1717 SHIPYARD BLVD
Provider Second Line Business Mailing Address:
STE 120
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28403-8019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-313-1511
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1717 SHIPYARD BLVD
Provider Second Line Business Practice Location Address:
STE 120
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28403-8019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-313-1511
Provider Business Practice Location Address Fax Number:
910-313-2520
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BUSH
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
910-313-1511

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  6905 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: 6805 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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