Provider Demographics
NPI:1265783310
Name:HEATON, TRAVIS GLENN (DDS)
Entity type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:GLENN
Last Name:HEATON
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 1:4700 KINSEY DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-1009
Mailing Address - Country:US
Mailing Address - Phone:903-245-9413
Mailing Address - Fax:
Practice Address - Street 1:4700 KINSEY DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-1009
Practice Address - Country:US
Practice Address - Phone:903-245-9413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-28
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX282441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice