Provider Demographics
NPI:1144673302
Name:BUCHANAN, JUSTIN (DMD)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:BUCHANAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54B MEIGS DR
Mailing Address - Street 2:
Mailing Address - City:SHALIMAR
Mailing Address - State:FL
Mailing Address - Zip Code:32579-2144
Mailing Address - Country:US
Mailing Address - Phone:678-591-9692
Mailing Address - Fax:
Practice Address - Street 1:101 4TH AVE STE D
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32539-2401
Practice Address - Country:US
Practice Address - Phone:850-683-3544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-22
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22127122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist