MEDICARE: DR. LUCIUS NELSON BUTLER IV

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	4308	AZ

General Provider Information

NPI Number	:	1598726192
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LUCIUS NELSON BUTLER IV

Provider Business Mailing Address
First Line	:	101 W BERRIDGE LN
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85013-1511
Country	:	US
Telephone Number	:	602-285-1417
Fax Number	:

Provider Business Practice Location Address
First Line	:	5406 W GLENN DR
Second Line	:	# 2
City	:	GLENDALE
State	:	AZ
Zip	:	85301-2662
Country	:	US
Telephone Number	:	623-937-2932
Fax Number	:	623-435-6921

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/31/2006
Last Update Date	:	07/08/2007

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