Provider Demographics
NPI:1467641100
Name:CROCKER, TRAVIS VANCE (DDS)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:VANCE
Last Name:CROCKER
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 1:3060 S. ALAMEDA ST
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78404
Mailing Address - Country:US
Mailing Address - Phone:361-882-1211
Mailing Address - Fax:361-882-7644
Practice Address - Street 1:3060 S. ALAMEDA ST
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78404
Practice Address - Country:US
Practice Address - Phone:361-882-1211
Practice Address - Fax:361-882-7644
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-18
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX147391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice