Provider Demographics
NPI:1750482246
Name:BUCKLEY, MARK ROBINSON
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ROBINSON
Last Name:BUCKLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 2 BOX 189
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47471-9759
Mailing Address - Country:US
Mailing Address - Phone:812-875-2505
Mailing Address - Fax:812-665-9374
Practice Address - Street 1:206 S MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:JASONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47438-1520
Practice Address - Country:US
Practice Address - Phone:812-665-2275
Practice Address - Fax:812-665-9374
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008304122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist