Provider Demographics
NPI:1003179011
Name:CASTLEBERRY, TRAVIS (DMD)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:CASTLEBERRY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 628
Mailing Address - Street 2:
Mailing Address - City:BLUE HILL
Mailing Address - State:ME
Mailing Address - Zip Code:04614-0628
Mailing Address - Country:US
Mailing Address - Phone:207-374-5538
Mailing Address - Fax:
Practice Address - Street 1:120 SOUTH ST
Practice Address - Street 2:
Practice Address - City:BLUE HILL
Practice Address - State:ME
Practice Address - Zip Code:04614-6120
Practice Address - Country:US
Practice Address - Phone:207-374-5538
Practice Address - Fax:207-613-2424
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-25
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME42471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice