Provider Demographics
NPI:1184021297
Name:TRAVIS, DALE KENNETH (DDS)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:KENNETH
Last Name:TRAVIS
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:PO BOX 606
Mailing Address - Street 2:
Mailing Address - City:WOODINVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98072-0606
Mailing Address - Country:US
Mailing Address - Phone:425-483-5959
Mailing Address - Fax:
Practice Address - Street 1:17416 135TH AVE NE
Practice Address - Street 2:
Practice Address - City:WOODINVILLE
Practice Address - State:WA
Practice Address - Zip Code:98072
Practice Address - Country:US
Practice Address - Phone:425-483-5959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-04
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA50371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice