MEDICARE: THE BUCKLEY DENTAL CENTER PC

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1558033050
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE BUCKLEY DENTAL CENTER PC

Provider Business Mailing Address
First Line	:	4807 WIGLEY RD NE
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30066-1503
Country	:	US
Telephone Number	:	678-524-7364
Fax Number	:

Provider Business Practice Location Address
First Line	:	2325 GLENWOOD AVE SE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30316-2362
Country	:	US
Telephone Number	:	678-800-8316
Fax Number	:	678-800-8317

Authorized Official
Title or Position	:	OWNER
Name	:	ELISHA ELISHA BUCKLEY
Credential	:
Telephone Number	:	678-524-7364

Provider Enumeration Date	:	10/02/2021
Last Update Date	:	10/02/2021

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