Provider Demographics
NPI:1982016671
Name:BROWN, TRAVIS (DMD)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:BROWN
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 1:205 E HARCOURT RD
Mailing Address - Street 2:
Mailing Address - City:ANGOLA
Mailing Address - State:IN
Mailing Address - Zip Code:46703-7131
Mailing Address - Country:US
Mailing Address - Phone:260-665-5767
Mailing Address - Fax:
Practice Address - Street 1:205 E HARCOURT RD
Practice Address - Street 2:
Practice Address - City:ANGOLA
Practice Address - State:IN
Practice Address - Zip Code:46703-7131
Practice Address - Country:US
Practice Address - Phone:260-665-5767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-29
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012126A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist