Provider Demographics
NPI:1356300586
Name:BUTTRICK, KELLY LOUISE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:LOUISE
Last Name:BUTTRICK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:LOUISE
Other - Last Name:BUTTRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:218 EMERSON RD
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-8802
Mailing Address - Country:US
Mailing Address - Phone:231-941-7057
Mailing Address - Fax:
Practice Address - Street 1:COMDT (CG-1122),U.S. COAST GUARD
Practice Address - Street 2:2100 2ND ST SW, SUITE 5314
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20593-0001
Practice Address - Country:US
Practice Address - Phone:231-922-8285
Practice Address - Fax:231-922-8292
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX159121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice