Provider Demographics
NPI:1093446163
Name:OLD OAKS DENTAL LLC
Entity type:Organization
Organization Name:OLD OAKS DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AARON
Authorized Official - Middle Name:
Authorized Official - Last Name:BUSHONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-573-3868
Mailing Address - Street 1:9809 39TH AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:PLEASANT PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53158-3733
Mailing Address - Country:US
Mailing Address - Phone:715-573-3868
Mailing Address - Fax:
Practice Address - Street 1:9809 39TH AVE STE 1
Practice Address - Street 2:
Practice Address - City:PLEASANT PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53158-3733
Practice Address - Country:US
Practice Address - Phone:715-573-3868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty