Provider Demographics
NPI:1235395476
Name:TRAVIS PRUNTY DDS PLLC
Entity Type:Organization
Organization Name:TRAVIS PRUNTY DDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS
Authorized Official - Prefix:DR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:PRUNTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-388-3023
Mailing Address - Street 1:PO BOX 894
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56002-0894
Mailing Address - Country:US
Mailing Address - Phone:507-388-3023
Mailing Address - Fax:507-388-3353
Practice Address - Street 1:730 E MADISON AVE
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6100
Practice Address - Country:US
Practice Address - Phone:507-388-3023
Practice Address - Fax:507-388-3353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-06
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12552261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental