Healthcare Provider Details

I. General information

NPI: 1386075638
Provider Name (Legal Business Name): BUSH & FREEDMAN ORTHODONTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2013
Last Update Date: 12/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3630 THOMPSON BRIDGE RD STE. 18B
GAINESVILLE GA
30506-1519
US

IV. Provider business mailing address

1740 HUDSON BRIDGE RD PMB 1182
STOCKBRIDGE GA
30281-6331
US

V. Phone/Fax

Practice location:
  • Phone: 678-769-4909
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN011309
License Number StateGA

VIII. Authorized Official

Name: DR. HECTOR BUSH
Title or Position: PARTNER
Credential: DMD
Phone: 678-769-4909