Healthcare Provider Details

I. General information

NPI: 1063586444
Provider Name (Legal Business Name): TIMMIE LEE BUTLER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: TIMMIE LEE BUTLER D.D.S.

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 EAST WASHINGTON STREET
AVON IL
61415-0379
US

IV. Provider business mailing address

PO BOX 379
AVON IL
61415-0379
US

V. Phone/Fax

Practice location:
  • Phone: 309-465-3165
  • Fax: 309-465-7695
Mailing address:
  • Phone: 309-465-3165
  • Fax: 309-465-7695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: