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General NPI Number Information
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NPI Number | 1104598457
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Entity Type | Organization
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Legal Business Name | ELISHA W BUCKLEY DDS PC
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Dates
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Enumeration Date | 10/04/2021
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Last Update Date | 10/04/2021
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Provider Practice Location Address
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Address Line | 540 E CROSSVILLE RD STE 200
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City | ROSWELL
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State | GA
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Zip | 30075-7661
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Country | US
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Telephone | 678-524-7364
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Fax |
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Provider Business Mailing Address
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Address Line | 4807 WIGLEY RD NE
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City | MARIETTA
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State | GA
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Zip | 30066-1503
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Country | US
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Telephone | 678-524-7364
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. ELISHA BUCKLEY
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Credential | DDS
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Telephone | 678-524-7364
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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