=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467587477
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JENNIFER EDWARDS BUTLER, DMD, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2007
-----------------------------------------------------
Last Update Date | 08/21/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2608 MAIN ST UNIT B
-----------------------------------------------------
City | CONWAY
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29526-3760
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-488-2526
-----------------------------------------------------
Fax | 843-488-2535
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2608 MAIN ST UNIT B
-----------------------------------------------------
City | CONWAY
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29526-3760
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-488-2526
-----------------------------------------------------
Fax | 843-488-2535
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JENNIFER EDWARDS BUTLER
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 843-488-2526
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 3767
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------