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General NPI Number Information
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NPI Number | 1144673302
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Entity Type | Individual
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Provider Name | JUSTIN BUCHANAN D.M.D.
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Gender | Male
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Dates
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Enumeration Date | 07/22/2016
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Last Update Date | 02/02/2017
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Provider Practice Location Address
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Address Line | 101 4TH AVE STE D
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City | CRESTVIEW
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State | FL
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Zip | 32539-2401
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Country | US
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Telephone | 850-683-3544
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Fax |
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Provider Business Mailing Address
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Address Line | 54B MEIGS DR
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City | SHALIMAR
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State | FL
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Zip | 32579-2144
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Country | US
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Telephone | 678-591-9692
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 22127
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License Number State | FL
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