Provider Demographics
NPI:1548202153
Name:BUTTERWORTH, ALICE MATILDA (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALICE
Middle Name:MATILDA
Last Name:BUTTERWORTH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:803 W GARDNER DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-1819
Mailing Address - Country:US
Mailing Address - Phone:765-664-0587
Mailing Address - Fax:765-664-1407
Practice Address - Street 1:803 W GARDNER DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-1819
Practice Address - Country:US
Practice Address - Phone:765-664-0587
Practice Address - Fax:765-664-1407
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-11
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007455A1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100143680AMedicaid