Provider Demographics
NPI:1467884395
Name:VERTOLLI, TRAVIS JONATHAN (DMD)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:JONATHAN
Last Name:VERTOLLI
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 1:6 BRITTANY LN
Mailing Address - Street 2:
Mailing Address - City:MILLVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08332-7261
Mailing Address - Country:US
Mailing Address - Phone:856-364-0304
Mailing Address - Fax:
Practice Address - Street 1:BUILDING H100 SANTA MARGARITA ROAD
Practice Address - Street 2:
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92055
Practice Address - Country:US
Practice Address - Phone:760-725-8882
Practice Address - Fax:760-725-1267
Is Sole Proprietor?:No
Enumeration Date:2013-08-02
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program