Provider Demographics
NPI:1417097213
Name:TRAVIS, STEPHEN MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:MICHAEL
Last Name:TRAVIS
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 1:2491 LINDEN DR
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-0427
Mailing Address - Country:US
Mailing Address - Phone:303-444-5998
Mailing Address - Fax:303-541-0101
Practice Address - Street 1:350 BROADWAY ST STE 10
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80305-3300
Practice Address - Country:US
Practice Address - Phone:303-494-8200
Practice Address - Fax:303-494-2281
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO48501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO84-1094885OtherIRS INDIVID. TAXPAYER ID#