Provider Demographics
NPI:1689161978
Name:BUCKSHIRE, KELLY JONES
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JONES
Last Name:BUCKSHIRE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 WILFORD HALL LOOP BLDG 4554
Mailing Address - Street 2:
Mailing Address - City:JBSA LACKLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78236-5638
Mailing Address - Country:US
Mailing Address - Phone:210-292-0747
Mailing Address - Fax:
Practice Address - Street 1:31ST MEDICAL GROUP/SGHC
Practice Address - Street 2:UNIT 6180
Practice Address - City:AVIANO
Practice Address - State:APO AE
Practice Address - Zip Code:09604
Practice Address - Country:IT
Practice Address - Phone:434-249-0195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-23
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA04014162151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program