=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447302096
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROOSEVELT BUSH JR. DDS MPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1111 PARK AVENUE
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21201-5656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-383-1800
-----------------------------------------------------
Fax | 410-772-5782
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1111 PARK AVENUE SUITE L9
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21201-5656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-383-1800
-----------------------------------------------------
Fax | 410-772-5782
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 4090
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------