Basic Information
| Provider Information | |||||||||
| NPI: | 1891136370 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUTLER | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | KEVIN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3325 RESEARCH WAY | ||||||||
| Address2: | |||||||||
| City: | CARSON CITY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 897067913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7758886610 | ||||||||
| FaxNumber: | 7758884904 | ||||||||
| Practice Location | |||||||||
| Address1: | 762 14TH ST | ||||||||
| Address2: | |||||||||
| City: | ELKO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 898013413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757381553 | ||||||||
| FaxNumber: | 7027385934 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2013 | ||||||||
| LastUpdateDate: | 09/16/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | D008786 | AZ | N | Dental Providers | Dentist | General Practice | 122300000X | DE60438463 | WA | N | Dental Providers | Dentist | 122300000X | 6671 | NV | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 1891136370 | 05 | NV | MEDICAID | 2033985 | 05 | WA | MEDICAID |