Provider Demographics
NPI:1447302096
Name:BUSH, ROOSEVELT JR (DDS MPH)
Entity type:Individual
Prefix:
First Name:ROOSEVELT
Middle Name:
Last Name:BUSH
Suffix:JR
Gender:M
Credentials:DDS MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 PARK AVENUE SUITE L9
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-5656
Mailing Address - Country:US
Mailing Address - Phone:410-383-1800
Mailing Address - Fax:410-772-5782
Practice Address - Street 1:1111 PARK AVENUE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-5656
Practice Address - Country:US
Practice Address - Phone:410-383-1800
Practice Address - Fax:410-772-5782
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD4090122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist