Provider Demographics
NPI:1811125651
Name:BUCKLEY, ELISHA W (DDS)
Entity type:Individual
Prefix:DR
First Name:ELISHA
Middle Name:W
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 E CROSSVILLE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-7661
Mailing Address - Country:US
Mailing Address - Phone:770-642-7999
Mailing Address - Fax:770-642-7912
Practice Address - Street 1:540 E CROSSVILLE RD STE 200
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-7661
Practice Address - Country:US
Practice Address - Phone:770-642-7999
Practice Address - Fax:770-642-7912
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-01
Last Update Date:2021-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0139111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice