Provider Demographics
NPI:1861681959
Name:ERIC P. BUETOW, D.D.S., P.C.
Entity Type:Organization
Organization Name:ERIC P. BUETOW, D.D.S., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MADDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-488-0861
Mailing Address - Street 1:PO BOX 56258
Mailing Address - Street 2:
Mailing Address - City:NORTH POLE
Mailing Address - State:AK
Mailing Address - Zip Code:99705-1258
Mailing Address - Country:US
Mailing Address - Phone:907-488-0861
Mailing Address - Fax:
Practice Address - Street 1:2933 HORSESHOE WAY
Practice Address - Street 2:
Practice Address - City:NORTH POLE
Practice Address - State:AK
Practice Address - Zip Code:99705-6122
Practice Address - Country:US
Practice Address - Phone:907-488-0861
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK5231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDDO523Medicaid