Healthcare Provider Details

I. General information

NPI: 1215171137
Provider Name (Legal Business Name): ERIC RAYMOND BUCKLEY DOM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2009
Last Update Date: 11/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 SAINT MICHAELS DR
SANTA FE NM
87505-7601
US

IV. Provider business mailing address

455 SAINT MICHAELS DR PHYSICIAN PRACTICES, ATTN: CARLA GOMEZ
SANTA FE NM
87505-7601
US

V. Phone/Fax

Practice location:
  • Phone: 505-913-5392
  • Fax: 505-989-6021
Mailing address:
  • Phone: 505-820-5227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number993
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number993
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: