Provider Demographics
NPI:1295733913
Name:TRAVELSTEAD, J SCOTT (DMD, PC)
Entity type:Individual
Prefix:DR
First Name:J
Middle Name:SCOTT
Last Name:TRAVELSTEAD
Suffix:
Gender:M
Credentials:DMD, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1823 NW KINGS BLVD
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-1907
Mailing Address - Country:US
Mailing Address - Phone:541-754-6400
Mailing Address - Fax:541-758-2081
Practice Address - Street 1:1823 NW KINGS BLVD
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-1907
Practice Address - Country:US
Practice Address - Phone:541-754-6400
Practice Address - Fax:541-758-2081
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILD73001223G0001X
ORD73001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice