Provider Demographics
NPI:1598726192
Name:BUTLER, LUCIUS NELSON IV
Entity Type:Individual
Prefix:DR
First Name:LUCIUS
Middle Name:NELSON
Last Name:BUTLER
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W BERRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-1511
Mailing Address - Country:US
Mailing Address - Phone:602-285-1417
Mailing Address - Fax:
Practice Address - Street 1:5406 W GLENN DR
Practice Address - Street 2:# 2
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-2662
Practice Address - Country:US
Practice Address - Phone:623-937-2932
Practice Address - Fax:623-435-6921
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ43081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice