1215171137 NPI number — DR. ERIC RAYMOND BUCKLEY DOM

Table of content: DR. ERIC RAYMOND BUCKLEY DOM (NPI 1215171137)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215171137 NPI number — DR. ERIC RAYMOND BUCKLEY DOM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUCKLEY
Provider First Name:
ERIC
Provider Middle Name:
RAYMOND
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DOM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215171137
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/05/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
455 SAINT MICHAELS DR
Provider Second Line Business Mailing Address:
PHYSICIAN PRACTICES, ATTN: CARLA GOMEZ
Provider Business Mailing Address City Name:
SANTA FE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87505-7601
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-820-5227
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
455 SAINT MICHAELS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA FE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87505-7601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-913-5392
Provider Business Practice Location Address Fax Number:
505-989-6021
Provider Enumeration Date:
04/22/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  993 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 174400000X , with the licence number: 993 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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