Provider Demographics
NPI:1467853945
Name:GRAHAM-WYATT, TRAVIS FRANKLIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:FRANKLIN
Last Name:GRAHAM-WYATT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:TRAVIS
Other - Middle Name:FRANKLIN
Other - Last Name:GRAHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:4730 COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:TX
Mailing Address - Zip Code:76384-4009
Mailing Address - Country:US
Mailing Address - Phone:940-552-9901
Mailing Address - Fax:
Practice Address - Street 1:4730 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:TX
Practice Address - Zip Code:76384-4009
Practice Address - Country:US
Practice Address - Phone:940-552-9901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-15
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30433122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist