Provider Demographics
NPI:1891817169
Name:MAGELSEN, TRAVIS JAMES (DMD)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:JAMES
Last Name:MAGELSEN
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:PO BOX 400
Mailing Address - Street 2:128 NORTH BLAKELY
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-0400
Mailing Address - Country:US
Mailing Address - Phone:360-794-8292
Mailing Address - Fax:360-794-8023
Practice Address - Street 1:128 N BLAKELEY ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1823
Practice Address - Country:US
Practice Address - Phone:360-794-8292
Practice Address - Fax:360-794-8023
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE 90331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice