Provider Demographics
NPI:1962628990
Name:GROSS, TRAVIS LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:LEE
Last Name:GROSS
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 1:7028 PLUM CREEK DR
Mailing Address - Street 2:
Mailing Address - City:SELLERSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47172-8919
Mailing Address - Country:US
Mailing Address - Phone:812-748-0057
Mailing Address - Fax:
Practice Address - Street 1:9419 STATE ROAD 403
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:IN
Practice Address - Zip Code:47111
Practice Address - Country:US
Practice Address - Phone:812-256-0606
Practice Address - Fax:812-256-0600
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010738A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice