MEDICARE: TODD MORONI BUSHMAN DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	24908	TX
2	122300000X	Dentist	24908	TX

General Provider Information

NPI Number	:	1831322668
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TODD MORONI BUSHMAN DMD

Provider Business Mailing Address
First Line	:	1121 LAKE AIR DR
Second Line	:
City	:	WACO
State	:	TX
Zip	:	76710-4417
Country	:	US
Telephone Number	:	254-772-8330
Fax Number	:

Provider Business Practice Location Address
First Line	:	1121 LAKE AIR DR
Second Line	:
City	:	WACO
State	:	TX
Zip	:	76710-4417
Country	:	US
Telephone Number	:	254-772-8330
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/27/2009
Last Update Date	:	04/16/2024

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