Healthcare Provider Details

I. General information

NPI: 1831265313
Provider Name (Legal Business Name): TIM L. BUTLER DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 WASHINGTON STREET
AVON IL
61415-0379
US

IV. Provider business mailing address

105 WASHINGTON STREET P.O. BOX 379
AVON IL
61415-0379
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number19015265
License Number StateIL

VIII. Authorized Official

Name: DR. TIMMIE LEE BUTLER
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 309-465-3165