Provider Demographics
NPI:1407862626
Name:TRAVIS, RANDOLPH THOMAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:THOMAS
Last Name:TRAVIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 PRIDE AVENUE
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-9108
Mailing Address - Country:US
Mailing Address - Phone:270-821-7386
Mailing Address - Fax:270-821-7401
Practice Address - Street 1:1400 PRIDE AVENUE
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-9108
Practice Address - Country:US
Practice Address - Phone:270-821-7386
Practice Address - Fax:270-821-7401
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY. 51411223P0221X
KYINDIANA 12010320A1223P0221X
OHOHIO 30.0196611223P0221X
KY51411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY600-51414Medicaid
KY45608965OtherEPSDT
IN200265680 AMedicaid