=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932916723
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JACOB K. BUSHNELL, DDS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2024
-----------------------------------------------------
Last Update Date | 12/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 N EDWARDS ST
-----------------------------------------------------
City | NEWBERG
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97132-2709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-538-7358
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 516 S COLLEGE ST
-----------------------------------------------------
City | NEWBERG
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97132-3312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-338-9823
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. JACOB K BUSHNELL
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 503-538-7358
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------