Provider Demographics
NPI:1720518541
Name:BUTALA, ANGELA (DMD)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:BUTALA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11508 MESSLER RD
Mailing Address - Street 2:
Mailing Address - City:GIBSONTON
Mailing Address - State:FL
Mailing Address - Zip Code:33534-5600
Mailing Address - Country:US
Mailing Address - Phone:813-731-6342
Mailing Address - Fax:
Practice Address - Street 1:5658 FISHHAWK CROSSING BLVD
Practice Address - Street 2:
Practice Address - City:LITHIA
Practice Address - State:FL
Practice Address - Zip Code:33547-5900
Practice Address - Country:US
Practice Address - Phone:813-490-1982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22737122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist