Provider Demographics
NPI:1730679168
Name:BRISENO, TRAVIS C (LD)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:C
Last Name:BRISENO
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6950 NE CAMPUS WAY
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-5611
Mailing Address - Country:US
Mailing Address - Phone:855-433-6825
Mailing Address - Fax:
Practice Address - Street 1:773 GOLF VIEW DR
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504
Practice Address - Country:US
Practice Address - Phone:855-433-6825
Practice Address - Fax:503-952-2267
Is Sole Proprietor?:No
Enumeration Date:2018-05-10
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDT-TMP-10190928122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist