Healthcare Provider Details

I. General information

NPI: 1245249275
Provider Name (Legal Business Name): LESLIE RICHERSON BUCKLEY DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30500 STATE HIGHWAY 181 STE 450
SPANISH FORT AL
36527-5824
US

IV. Provider business mailing address

30500 STATE HIGHWAY 181 STE 450
SPANISH FORT AL
36527-5824
US

V. Phone/Fax

Practice location:
  • Phone: 251-625-1908
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5121
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: