Healthcare Provider Details

I. General information

NPI: 1083530489
Provider Name (Legal Business Name): DOMINIQUE DEVONE BUCKLES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 HUBBARD ST
DETROIT MI
48209-2483
US

IV. Provider business mailing address

8755 QUINCY ST
DETROIT MI
48204-2365
US

V. Phone/Fax

Practice location:
  • Phone: 586-420-3488
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372500000X
TaxonomyChore Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: