Healthcare Provider Details

I. General information

NPI: 1366922676
Provider Name (Legal Business Name): DR. KENNETH TUSHA DDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2018
Last Update Date: 08/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 W MAIN ST
BLOOMFIELD NE
68718-4035
US

IV. Provider business mailing address

309 W MAIN ST
BLOOMFIELD NE
68718-4035
US

V. Phone/Fax

Practice location:
  • Phone: 402-668-2297
  • Fax: 402-668-2297
Mailing address:
  • Phone: 402-668-2297
  • Fax: 402-668-2297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number5042
License Number StateNE

VIII. Authorized Official

Name: DR. KENNETH R. TUSHA
Title or Position: PROVIDER
Credential: DDS
Phone: 402-394-7254