Provider Demographics
NPI:1821672619
Name:FERNALD, TRAVIS LUX (DMD)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:LUX
Last Name:FERNALD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 N SHERIDAN AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15206-2521
Mailing Address - Country:US
Mailing Address - Phone:484-356-7349
Mailing Address - Fax:
Practice Address - Street 1:320 E NORTH AVE STE 111
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15212-4756
Practice Address - Country:US
Practice Address - Phone:412-359-3685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-08
Last Update Date:2021-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program