Provider Demographics
NPI:1669913182
Name:ALICE M. BUTTERWORTH, D.D.S.
Entity type:Organization
Organization Name:ALICE M. BUTTERWORTH, D.D.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-664-0587
Mailing Address - Street 1:803 W GARDNER DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-1819
Mailing Address - Country:US
Mailing Address - Phone:765-664-0587
Mailing Address - Fax:765-664-1407
Practice Address - Street 1:803 W GARDNER DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-1819
Practice Address - Country:US
Practice Address - Phone:765-664-0587
Practice Address - Fax:765-664-1407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-16
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120074551223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100143680Medicaid