Provider Demographics
NPI:1194394627
Name:ADUDDELL, TRAVIS CARBY (DDS)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:CARBY
Last Name:ADUDDELL
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 1:821 ALLEN ST APT 211
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-5784
Mailing Address - Country:US
Mailing Address - Phone:281-703-0361
Mailing Address - Fax:
Practice Address - Street 1:271 E SOUTHLAKE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6272
Practice Address - Country:US
Practice Address - Phone:817-329-6677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-19
Last Update Date:2021-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37277122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist