Provider Demographics
NPI:1821420324
Name:DUFFY, JOHN TRAVIS (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:TRAVIS
Last Name:DUFFY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:J. TRAVIS
Other - Middle Name:
Other - Last Name:DUFFY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:640 12TH ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4001
Mailing Address - Country:US
Mailing Address - Phone:503-364-7944
Mailing Address - Fax:503-585-8902
Practice Address - Street 1:640 12TH ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4001
Practice Address - Country:US
Practice Address - Phone:503-364-7944
Practice Address - Fax:503-585-8902
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-07
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9931122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist