Provider Demographics
NPI:1295852655
Name:LUTZ, TRAVIS DUANE (DDS)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:DUANE
Last Name:LUTZ
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 316
Mailing Address - Street 2:
Mailing Address - City:CELINA
Mailing Address - State:OH
Mailing Address - Zip Code:45822-0316
Mailing Address - Country:US
Mailing Address - Phone:419-586-1615
Mailing Address - Fax:
Practice Address - Street 1:800 E WAYNE ST
Practice Address - Street 2:
Practice Address - City:CELINA
Practice Address - State:OH
Practice Address - Zip Code:45822-1359
Practice Address - Country:US
Practice Address - Phone:419-586-1615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.020826122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9182631OtherDORAL
OH06131OtherPARAMOUNT
OH2057965Medicaid