Provider Demographics
NPI:1629114384
Name:BUTTRAM, CHARLES JAMES JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:JAMES
Last Name:BUTTRAM
Suffix:JR
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 1:162 HOSPITAL DR
Mailing Address - Street 2:P.O. BOX 1206
Mailing Address - City:RATON
Mailing Address - State:NM
Mailing Address - Zip Code:87740-2002
Mailing Address - Country:US
Mailing Address - Phone:505-445-3596
Mailing Address - Fax:
Practice Address - Street 1:162 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:RATON
Practice Address - State:NM
Practice Address - Zip Code:87740-2002
Practice Address - Country:US
Practice Address - Phone:505-445-3596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM10591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice