Provider Demographics
NPI:1548541279
Name:BUSH, MARY A (DDS)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:A
Last Name:BUSH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4473 HARRIS HILL RD
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14221-6205
Mailing Address - Country:US
Mailing Address - Phone:716-829-3561
Mailing Address - Fax:716-829-3006
Practice Address - Street 1:3435 MAIN ST
Practice Address - Street 2:SQUIRE HALL
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214-3001
Practice Address - Country:US
Practice Address - Phone:716-829-3561
Practice Address - Fax:716-829-3006
Is Sole Proprietor?:No
Enumeration Date:2011-09-08
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048307-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist