Healthcare Provider Details

I. General information

NPI: 1376615880
Provider Name (Legal Business Name): NEVIL PHILLIP BUSH DDS PC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 A SHERWOOD PARK DR NE
GAINESVILLE GA
30501
US

IV. Provider business mailing address

1221 A SHERWOOD PARK DR NE
GAINESVILLE GA
30501
US

V. Phone/Fax

Practice location:
  • Phone: 770-536-2183
  • Fax: 770-534-8309
Mailing address:
  • Phone: 770-536-2183
  • Fax: 770-534-8309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number7529
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: