Provider Demographics
NPI:1386096758
Name:BUCKLEIN, STACEY (EFDA)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:BUCKLEIN
Suffix:
Gender:F
Credentials:EFDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 MCLOUGHLIN BLVD
Mailing Address - Street 2:SUITE 68
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-1067
Mailing Address - Country:US
Mailing Address - Phone:503-387-8000
Mailing Address - Fax:503-387-8005
Practice Address - Street 1:1900 MCLOUGHLIN BLVD
Practice Address - Street 2:SUITE 68
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-1067
Practice Address - Country:US
Practice Address - Phone:503-387-8000
Practice Address - Fax:503-387-8005
Is Sole Proprietor?:No
Enumeration Date:2016-07-08
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR120315126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant