MEDICARE: PARKDALE DENTAL CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1467028969
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PARKDALE DENTAL CENTER LLC

Provider Business Mailing Address
First Line	:	5764 WINDY DR
Second Line	:
City	:	STEVENS POINT
State	:	WI
Zip	:	54482-8486
Country	:	US
Telephone Number	:	715-341-2220
Fax Number	:

Provider Business Practice Location Address
First Line	:	5764 WINDY DR
Second Line	:
City	:	STEVENS POINT
State	:	WI
Zip	:	54482-8486
Country	:	US
Telephone Number	:	715-341-2220
Fax Number	:

Authorized Official
Title or Position	:	DENTIST/OWNER
Name	:	DR. AARON J BUSHONG
Credential	:	DDS
Telephone Number	:	715-573-3546

Provider Enumeration Date	:	06/03/2021
Last Update Date	:	06/03/2021

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