Provider Demographics
NPI:1295928125
Name:WILES, TRAVIS CHARLES (DDS)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:CHARLES
Last Name:WILES
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:PO BOX 455
Mailing Address - Street 2:J ALLEN BURLESON DDS PC
Mailing Address - City:JONESBOROUGH
Mailing Address - State:TN
Mailing Address - Zip Code:37659-0455
Mailing Address - Country:US
Mailing Address - Phone:423-753-9191
Mailing Address - Fax:423-753-9644
Practice Address - Street 1:222 HEADTOWN RD
Practice Address - Street 2:J ALLEN BURLESON DDS PC
Practice Address - City:JONESBOROUGH
Practice Address - State:TN
Practice Address - Zip Code:37659-0455
Practice Address - Country:US
Practice Address - Phone:423-753-9191
Practice Address - Fax:423-753-9644
Is Sole Proprietor?:No
Enumeration Date:2007-08-23
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8721122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist