Healthcare Provider Details

I. General information

NPI: 1134103211
Provider Name (Legal Business Name): LOUIS R BUSH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 04/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 MEDICAL CENTER RD
EDGEWOOD NM
87015-7086
US

IV. Provider business mailing address

2001 CENTRO FAMILIAR BLVD SW
ALBUQUERQUE NM
87105-4592
US

V. Phone/Fax

Practice location:
  • Phone: 505-873-7405
  • Fax: 505-873-7444
Mailing address:
  • Phone: 505-873-7405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD2580
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: