Provider Demographics
NPI:1255302105
Name:THOMPSON, TRAVIS
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 MILITARY TRAIL
Mailing Address - Street 2:SUITE 110
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458
Mailing Address - Country:US
Mailing Address - Phone:561-743-8311
Mailing Address - Fax:561-744-6201
Practice Address - Street 1:1025 MILITARY TRAIL
Practice Address - Street 2:SUITE 110
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458
Practice Address - Country:US
Practice Address - Phone:561-743-8311
Practice Address - Fax:561-744-6201
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN146701223P0106X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Not Answered1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL21976Medicare ID - Type Unspecified
FLU86458Medicare UPIN