Healthcare Provider Details

I. General information

NPI: 1093709685
Provider Name (Legal Business Name): JOSEPH JOHN BUTASEK SR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

238 BROOKLEY AVE
BOLLING AFB DC
20037-7050
US

IV. Provider business mailing address

1120 ALDEN RD
ALEXANDRIA VA
22308-2554
US

V. Phone/Fax

Practice location:
  • Phone: 202-767-5626
  • Fax:
Mailing address:
  • Phone: 703-799-6614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS019232L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: