Provider Demographics
NPI:1679878938
Name:SORENSEN, TRAVIS M (DDS)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:M
Last Name:SORENSEN
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 1:2185 N ROBINS DR STE 204
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-1192
Mailing Address - Country:US
Mailing Address - Phone:801-335-4510
Mailing Address - Fax:
Practice Address - Street 1:2185 N ROBINS DR STE 204
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-1192
Practice Address - Country:US
Practice Address - Phone:801-335-4546
Practice Address - Fax:801-335-4546
Is Sole Proprietor?:No
Enumeration Date:2011-01-18
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ93491223S0112X
NV64921223S0112X
UT123961501223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery