Provider Demographics
NPI:1639119969
Name:BUTLER, KELLY ANN (DDS)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:BUTLER
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 1:11517 PACIFIC AVE S
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98444-5535
Mailing Address - Country:US
Mailing Address - Phone:360-897-9262
Mailing Address - Fax:
Practice Address - Street 1:11517 PACIFIC AVE S
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98444-5535
Practice Address - Country:US
Practice Address - Phone:253-537-6511
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA78381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice