Provider Demographics
NPI:1043440282
Name:WILLEY, TRAVIS R (DDS)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:R
Last Name:WILLEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4745 BOARDWALK DR STE D102
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-3773
Mailing Address - Country:US
Mailing Address - Phone:970-223-6101
Mailing Address - Fax:970-530-1593
Practice Address - Street 1:4745 BOARDWALK DR STE D102
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-3773
Practice Address - Country:US
Practice Address - Phone:970-223-6101
Practice Address - Fax:970-530-1593
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9980122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist