Provider Demographics
NPI:1760744619
Name:SISCO, TRAVIS WAYNE (DDS)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:WAYNE
Last Name:SISCO
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 1:201 ROSE RD
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:TN
Mailing Address - Zip Code:37763-3416
Mailing Address - Country:US
Mailing Address - Phone:931-260-3028
Mailing Address - Fax:
Practice Address - Street 1:513 W CUMBERLAND ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:TN
Practice Address - Zip Code:37763-2710
Practice Address - Country:US
Practice Address - Phone:865-248-8361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-15
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9481122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist