Provider Demographics
NPI:1215412572
Name:BUSCHBACH, JACQUELINE COLLEEN (DMD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:COLLEEN
Last Name:BUSCHBACH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 HAMILTON PKWY
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13214-2312
Mailing Address - Country:US
Mailing Address - Phone:773-320-9352
Mailing Address - Fax:
Practice Address - Street 1:4 CHENANGO ST
Practice Address - Street 2:
Practice Address - City:CAZENOVIA
Practice Address - State:NY
Practice Address - Zip Code:13035-1400
Practice Address - Country:US
Practice Address - Phone:570-735-8754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-02
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY060956122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist