Provider Demographics
NPI:1750301206
Name:BUCKLEY, DOUGLAS R (DDS)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:R
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 1:2058 S DOBSON RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-6454
Mailing Address - Country:US
Mailing Address - Phone:480-345-8597
Mailing Address - Fax:
Practice Address - Street 1:2058 S DOBSON RD
Practice Address - Street 2:SUITE 3
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-6454
Practice Address - Country:US
Practice Address - Phone:480-345-8597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ19821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice