Provider Demographics
NPI:1891136370
Name:BUTLER, JACOB KEVIN (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:KEVIN
Last Name:BUTLER
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12219 E CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-2808
Mailing Address - Country:US
Mailing Address - Phone:316-681-1099
Mailing Address - Fax:316-613-2417
Practice Address - Street 1:12219 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-2808
Practice Address - Country:US
Practice Address - Phone:316-681-1099
Practice Address - Fax:316-613-2417
Is Sole Proprietor?:No
Enumeration Date:2013-07-11
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS613091223E0200X
WADE60438463122300000X
NV6671122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1891136370Medicaid
WA2033985Medicaid