Healthcare Provider Details

I. General information

NPI: 1255427480
Provider Name (Legal Business Name): TIMOTHY JAY BUSSICK DDS, MS, INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 04/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7207 ENGLE RD
FORT WAYNE IN
46804-2231
US

IV. Provider business mailing address

7207 ENGLE RD
FORT WAYNE IN
46804-2231
US

V. Phone/Fax

Practice location:
  • Phone: 260-436-2255
  • Fax: 260-432-5466
Mailing address:
  • Phone: 260-436-2255
  • Fax: 260-432-5466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number12009656
License Number StateIN

VIII. Authorized Official

Name: DR. TIMOTHY JAY BUSSICK
Title or Position: PRESIDENT/CEO
Credential: DDS, MS
Phone: 260-436-2255