MEDICARE: DR. TERRY LEE BUCKENHEIMER 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	8669	FL

General Provider Information

NPI Number	:	1548665532
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TERRY LEE BUCKENHEIMER DMD

Provider Business Mailing Address
First Line	:	3906 W NEPTUNE ST
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33629-5829
Country	:	US
Telephone Number	:	813-857-3989
Fax Number	:	813-259-9923

Provider Business Practice Location Address
First Line	:	3906 W NEPTUNE ST
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33629-5829
Country	:	US
Telephone Number	:	813-857-3989
Fax Number	:	813-259-9923

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

Provider Enumeration Date	:	11/03/2014
Last Update Date	:	11/03/2014

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