Provider Demographics
NPI:1902377344
Name:BUTLER PIKE PERIODONTAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:BUTLER PIKE PERIODONTAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:L
Authorized Official - Last Name:FAVA
Authorized Official - Suffix:II
Authorized Official - Credentials:DMD
Authorized Official - Phone:267-643-4393
Mailing Address - Street 1:140 E BUTLER AVE
Mailing Address - Street 2:
Mailing Address - City:AMBLER
Mailing Address - State:PA
Mailing Address - Zip Code:19002-4427
Mailing Address - Country:US
Mailing Address - Phone:267-643-4393
Mailing Address - Fax:
Practice Address - Street 1:140 E BUTLER AVE
Practice Address - Street 2:
Practice Address - City:AMBLER
Practice Address - State:PA
Practice Address - Zip Code:19002-4427
Practice Address - Country:US
Practice Address - Phone:267-643-4393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-11
Last Update Date:2019-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty