MEDICARE: BUCKNER RSVG PLLC

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1669858213
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BUCKNER RSVG PLLC

Provider Business Mailing Address
First Line	:	2702 S BUCKNER BLVD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75227-6903
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2702 S BUCKNER BLVD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75227-6903
Country	:	US
Telephone Number	:	214-493-1216
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	JOSE GONZALEZ
Credential	:
Telephone Number	:	214-493-1216

Provider Enumeration Date	:	08/06/2015
Last Update Date	:	08/06/2015

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