=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699257535
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN A. KUSH, D.M.D., LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2018
-----------------------------------------------------
Last Update Date | 09/06/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1484 HIGHWAY 31
-----------------------------------------------------
City | ANNANDALE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-730-0090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 47 LA COSTA DR
-----------------------------------------------------
City | ANNANDALE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08801-1663
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-730-7119
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | JOHN A. KUSH
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 908-730-0090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------