Provider Demographics
NPI:1265682686
Name:MIZE, TRAVIS WAYNE (DMD, MHS)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:WAYNE
Last Name:MIZE
Suffix:
Gender:M
Credentials:DMD, MHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 MEDICAL CIR
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-3655
Mailing Address - Country:US
Mailing Address - Phone:803-794-7520
Mailing Address - Fax:
Practice Address - Street 1:159 MEDICAL CIR
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-3655
Practice Address - Country:US
Practice Address - Phone:803-794-7520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-22
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4466122300000X
MADN18555031223P0300X
SC8261223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist