Provider Demographics
NPI:1043717382
Name:TRAVIS WILLEY, DDS PC
Entity Type:Organization
Organization Name:TRAVIS WILLEY, DDS PC
Other - Org Name:FAMILY & COSMETIC DENTISTRY OF THE ROCKIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:VENEKAMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-223-6101
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:
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-12
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty