Provider Demographics
NPI:1649566654
Name:TRAVIS, MICHAEL PATRICK (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:PATRICK
Last Name:TRAVIS
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 1:3708 JENNINGS STATION RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63121-3500
Mailing Address - Country:US
Mailing Address - Phone:314-382-2000
Mailing Address - Fax:
Practice Address - Street 1:3708 JENNINGS STATION RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63121-3500
Practice Address - Country:US
Practice Address - Phone:314-382-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-28
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20110197451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice