Active NPI
Roosevelt Bush Jr., DDS MPH
- Dentist
- Baltimore, MD
National Provider Identifier
1447302096
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 4090
- Practice address
- 1111 Park Avenue
Baltimore, MD 21201-5656 - Phone
- (410) 383-1800
- Fax
- (410) 772-5782
- NPI assigned
- Jan 16, 2007
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 4090 | MD | Primary |
Addresses
Primary practice location
1111 Park Avenue
Baltimore, MD 21201-5656
Mailing address
1111 Park Avenue Suite L9
Baltimore, MD 21201-5656
Phone (410) 383-1800
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 4090 | MD | MD | Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1168905600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1447302096",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1111 PARK AVENUE SUITE L9",
"city": "BALTIMORE",
"state": "MD",
"postal_code": "212015656",
"telephone_number": "410-383-1800",
"fax_number": "410-772-5782"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1111 PARK AVENUE",
"city": "BALTIMORE",
"state": "MD",
"postal_code": "212015656",
"telephone_number": "410-383-1800",
"fax_number": "410-772-5782"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BUSH",
"first_name": "ROOSEVELT",
"name_suffix": "Jr.",
"credential": "DDS MPH",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2007-01-16",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "MD",
"license": "4090",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Baltimore, MD
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.