Provider Demographics
NPI:1457026015
Name:TRAVERS DENTAL GROUP INCORPORATED
Entity Type:Organization
Organization Name:TRAVERS DENTAL GROUP INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAVERS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:312-342-2299
Mailing Address - Street 1:828 JACKMAN ST
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-3053
Mailing Address - Country:US
Mailing Address - Phone:312-342-2299
Mailing Address - Fax:
Practice Address - Street 1:828 JACKMAN ST
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-3053
Practice Address - Country:US
Practice Address - Phone:312-342-2299
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-14
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA61514OtherDENTIST