Provider Demographics
NPI:1477781813
Name:EDWARDS, TRAVIS L (DDS)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:L
Last Name:EDWARDS
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 1:351 W IOWA AVE
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-2856
Mailing Address - Country:US
Mailing Address - Phone:208-461-2600
Mailing Address - Fax:
Practice Address - Street 1:4106 WAKE FOREST RD STE 201
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-6397
Practice Address - Country:US
Practice Address - Phone:919-277-0577
Practice Address - Fax:919-390-0019
Is Sole Proprietor?:No
Enumeration Date:2009-06-24
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4211122300000X
NC127921223G0001X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice