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General NPI Number Information
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NPI Number | 1326701632
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Entity Type | Organization
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Legal Business Name | LOOMIS ROAD DENTAL CENTER LLC
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Dates
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Enumeration Date | 10/14/2021
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Last Update Date | 10/14/2021
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Provider Practice Location Address
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Address Line | 9700 W LOOMIS RD
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City | FRANKLIN
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State | WI
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Zip | 53132-9701
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Country | US
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Telephone | 414-529-3933
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Fax |
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Provider Business Mailing Address
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Address Line | 301 N 17TH AVE STE 200
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City | WAUSAU
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State | WI
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Zip | 54401-4225
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Country | US
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Telephone | 715-573-3546
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Fax |
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Authorized Official
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Title or Position | DENTIST/OWNER
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Name | AARON BUSHONG
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Credential | DDS
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Telephone | 715-573-3546
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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