Provider Demographics
NPI:1659503803
Name:AGEE, TRAVIS LEE (DMD)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:LEE
Last Name:AGEE
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 1:6439 NE SANDY BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-4505
Mailing Address - Country:US
Mailing Address - Phone:503-284-3588
Mailing Address - Fax:503-284-3694
Practice Address - Street 1:6439 NE SANDY BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-4505
Practice Address - Country:US
Practice Address - Phone:503-284-3588
Practice Address - Fax:503-284-3694
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-20
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD93351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice