Basic Information
Provider Information | |||||||||
NPI: | 1851880934 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BUSHMAN | ||||||||
FirstName: | RYAN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DMD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 919 N PINES RD | ||||||||
Address2: |   | ||||||||
City: | SPOKANE VALLEY | ||||||||
State: | WA | ||||||||
PostalCode: | 992064932 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5099240381 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 919 N PINES RD | ||||||||
Address2: |   | ||||||||
City: | SPOKANE VALLEY | ||||||||
State: | WA | ||||||||
PostalCode: | 99206 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5099240381 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/04/2018 | ||||||||
LastUpdateDate: | 09/26/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DE60855064 | WA | Y |   | Dental Providers | Dentist |   |
ID Information
ID | Type | State | Issuer | Description | 153536142 | 01 |   | AMERICAN DENTAL ASSOCIATION | OTHER | 2102572 | 05 | WA |   | MEDICAID | DE60855064 | 01 | WA | WA STATE DEPARTMENT OF HEALTH | OTHER |