Provider Demographics
NPI:1548534415
Name:BUSHEY ORAL AND MAXILLOFACIAL SURGERY, INC.
Entity type:Organization
Organization Name:BUSHEY ORAL AND MAXILLOFACIAL SURGERY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:EDMOND
Authorized Official - Last Name:BUSHEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:330-758-0561
Mailing Address - Street 1:7081 WEST BLVD.
Mailing Address - Street 2:SUITE 1
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44512
Mailing Address - Country:US
Mailing Address - Phone:330-758-0561
Mailing Address - Fax:
Practice Address - Street 1:7081 WEST BLVD.
Practice Address - Street 2:SUITE 1
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44512
Practice Address - Country:US
Practice Address - Phone:330-758-0561
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-24
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH142711223S0112X
OH1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty