Provider Demographics
NPI:1699203109
Name:BASKERVILLE, TRAVIS ROYCE (DMD)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:ROYCE
Last Name:BASKERVILLE
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 1:503 N 41ST AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:WA
Mailing Address - Zip Code:98642-8074
Mailing Address - Country:US
Mailing Address - Phone:503-709-9322
Mailing Address - Fax:
Practice Address - Street 1:12116 SE MILL PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684
Practice Address - Country:US
Practice Address - Phone:360-256-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-28
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60772184122300000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist