Provider Demographics
NPI:1154487718
Name:ELDER, TRAVIS T (DMD)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:T
Last Name:ELDER
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 1:907 HELENA AVE
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59601-3425
Mailing Address - Country:US
Mailing Address - Phone:406-442-4990
Mailing Address - Fax:406-442-4939
Practice Address - Street 1:907 HELENA AVE
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601-3425
Practice Address - Country:US
Practice Address - Phone:406-442-4990
Practice Address - Fax:406-442-4939
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT19591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000110955Medicaid