Healthcare Provider Details

I. General information

NPI: 1548534415
Provider Name (Legal Business Name): BUSHEY ORAL AND MAXILLOFACIAL SURGERY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2012
Last Update Date: 04/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7081 WEST BLVD. SUITE 1
YOUNGSTOWN OH
44512
US

IV. Provider business mailing address

7081 WEST BLVD. SUITE 1
YOUNGSTOWN OH
44512
US

V. Phone/Fax

Practice location:
  • Phone: 330-758-0561
  • Fax:
Mailing address:
  • Phone: 330-758-0561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number14271
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number StateOH

VIII. Authorized Official

Name: DR. MICHAEL EDMOND BUSHEY
Title or Position: CHAIRMAN
Credential: D.D.S.
Phone: 330-758-0561