Provider Demographics
NPI:1760412258
Name:SCOGGIN, TRAVIS KENT (DDS)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:KENT
Last Name:SCOGGIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:KENT
Other - Middle Name:
Other - Last Name:SCOGGIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:318 MELVILLE DR
Mailing Address - Street 2:
Mailing Address - City:PAULS VALLEY
Mailing Address - State:OK
Mailing Address - Zip Code:73075
Mailing Address - Country:US
Mailing Address - Phone:405-238-3600
Mailing Address - Fax:405-238-1640
Practice Address - Street 1:318 MELVILLE DR
Practice Address - Street 2:
Practice Address - City:PAULS VALLEY
Practice Address - State:OK
Practice Address - Zip Code:73075
Practice Address - Country:US
Practice Address - Phone:405-238-3600
Practice Address - Fax:405-238-1640
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4705122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100147060AMedicaid