Provider Demographics
NPI:1235542903
Name:REYNOSO, AUDRA BUCKLEY (DMD)
Entity Type:Individual
Prefix:DR
First Name:AUDRA
Middle Name:BUCKLEY
Last Name:REYNOSO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:AUDRA
Other - Middle Name:LEAH
Other - Last Name:BUCKLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:809 E 4TH ST
Mailing Address - Street 2:UNIT 3
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-3242
Mailing Address - Country:US
Mailing Address - Phone:781-258-5127
Mailing Address - Fax:
Practice Address - Street 1:100 AMESBURY ST
Practice Address - Street 2:SUITE 110
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01840-1321
Practice Address - Country:US
Practice Address - Phone:978-686-3838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-10
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18566011223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics