Provider Demographics
NPI:1942380563
Name:HANEL, TRAVIS (DDS)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:HANEL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 W JOHNSON AVE
Mailing Address - Street 2:STE. 3
Mailing Address - City:WARREN
Mailing Address - State:MN
Mailing Address - Zip Code:56762-1118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:205 W JOHNSON AVE
Practice Address - Street 2:STE 3
Practice Address - City:WARREN
Practice Address - State:MN
Practice Address - Zip Code:56762-1118
Practice Address - Country:US
Practice Address - Phone:218-745-4601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND120241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN473990600Medicaid