Provider Demographics
NPI:1922181999
Name:WILSON, TRAVIS W (DMD)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:W
Last Name:WILSON
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 1:1042 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:KY
Mailing Address - Zip Code:42320-1553
Mailing Address - Country:US
Mailing Address - Phone:270-274-3645
Mailing Address - Fax:270-274-3452
Practice Address - Street 1:1042 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:KY
Practice Address - Zip Code:42320-1553
Practice Address - Country:US
Practice Address - Phone:270-274-3645
Practice Address - Fax:270-274-3452
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY71991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice