Provider Demographics
NPI:1679001085
Name:RUSSELL, TRAVIS RAY (DDS)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:RAY
Last Name:RUSSELL
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 1:594 MAIN ST N
Mailing Address - Street 2:
Mailing Address - City:MC KENZIE
Mailing Address - State:TN
Mailing Address - Zip Code:38201-1707
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:594 MAIN ST N
Practice Address - Street 2:
Practice Address - City:MC KENZIE
Practice Address - State:TN
Practice Address - Zip Code:38201-1707
Practice Address - Country:US
Practice Address - Phone:731-415-3084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-30
Last Update Date:2017-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10509122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist