Provider Demographics
NPI:1174695803
Name:BUETOW, ERIC P (DDS)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:P
Last Name:BUETOW
Suffix:
Gender:M
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:PO BOX 56258
Mailing Address - Street 2:2933 HORSESHOE WAY
Mailing Address - City:NORTH POLE
Mailing Address - State:AK
Mailing Address - Zip Code:99705
Mailing Address - Country:US
Mailing Address - Phone:907-488-0861
Mailing Address - Fax:907-488-3141
Practice Address - Street 1:2933 HORSESHOE WAY
Practice Address - Street 2:
Practice Address - City:NORTH POLE
Practice Address - State:AK
Practice Address - Zip Code:99705
Practice Address - Country:US
Practice Address - Phone:907-488-0861
Practice Address - Fax:907-488-3141
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK523122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDDO523Medicaid