Healthcare Provider Details

I. General information

NPI: 1740113562
Provider Name (Legal Business Name): TAYLOR BUSHMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2026
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 STARFIRE DR
OTTAWA IL
61350-1624
US

IV. Provider business mailing address

2738 E 2625TH RD
MARSEILLES IL
61341-9484
US

V. Phone/Fax

Practice location:
  • Phone: 815-433-3413
  • Fax:
Mailing address:
  • Phone: 815-830-3344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.037132
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: