Provider Demographics
NPI:1760063135
Name:MACKEY, TRAVIS JAMES
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:JAMES
Last Name:MACKEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-8012
Mailing Address - Country:US
Mailing Address - Phone:631-942-1332
Mailing Address - Fax:
Practice Address - Street 1:496 COUNTY ROAD 111 BLDG F
Practice Address - Street 2:
Practice Address - City:MANORVILLE
Practice Address - State:NY
Practice Address - Zip Code:11949-3383
Practice Address - Country:US
Practice Address - Phone:631-929-5855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-17
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY062492122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist