MEDICARE: JACQUELINE COLLEEN BUSCHBACH DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	060956	NY

General Provider Information

NPI Number	:	1215412572
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE COLLEEN BUSCHBACH DMD

Provider Business Mailing Address
First Line	:	603 HAMILTON PKWY
Second Line	:
City	:	SYRACUSE
State	:	NY
Zip	:	13214-2312
Country	:	US
Telephone Number	:	773-320-9352
Fax Number	:

Provider Business Practice Location Address
First Line	:	4 CHENANGO ST
Second Line	:
City	:	CAZENOVIA
State	:	NY
Zip	:	13035-1400
Country	:	US
Telephone Number	:	570-735-8754
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/02/2018
Last Update Date	:	06/02/2020

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