Healthcare Provider Details

I. General information

NPI: 1083693774
Provider Name (Legal Business Name): JUSTIN DANIEL BUCHANAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG 9900, 2ND FLOOR U.S. ARMY DENTAL ACTIVITY - FT LEWIS
TACOMA WA
98431-0001
US

IV. Provider business mailing address

BLDG 9900, 2ND FLOOR U.S. ARMY DENTAL ACTIVITY - FT LEWIS
TACOMA WA
98431-0001
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-4039
  • Fax: 253-968-5919
Mailing address:
  • Phone: 253-968-4039
  • Fax: 253-968-5919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD 8167
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: