Provider Demographics
NPI:1922248095
Name:GREEN, TRAVIS (DMD)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:
Last Name:GREEN
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 1:151 SHORESIDE DR
Mailing Address - Street 2:APT. 14106
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40515-6442
Mailing Address - Country:US
Mailing Address - Phone:859-421-2518
Mailing Address - Fax:
Practice Address - Street 1:1101 VETERANS DRIVE (160-CDD)
Practice Address - Street 2:VA MEDICAL CENTER
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40502
Practice Address - Country:US
Practice Address - Phone:859-281-4912
Practice Address - Fax:859-381-5911
Is Sole Proprietor?:No
Enumeration Date:2009-03-02
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY86201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice