Provider Demographics
NPI:1679981153
Name:BUCKLEY, PHILLIP (DDS)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:BUCKLEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 TAMARISK DR
Mailing Address - Street 2:
Mailing Address - City:LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66048-5594
Mailing Address - Country:US
Mailing Address - Phone:314-566-9072
Mailing Address - Fax:
Practice Address - Street 1:525 E SPRINGFIELD RD
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR
Practice Address - State:MO
Practice Address - Zip Code:63077-1735
Practice Address - Country:US
Practice Address - Phone:636-629-1103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-28
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014016767122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist