Provider Demographics
NPI:1457054876
Name:RABUN, TRAVIS BLAKE (DDS)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:BLAKE
Last Name:RABUN
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 1:3506 LOCHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-2995
Mailing Address - Country:US
Mailing Address - Phone:720-331-4401
Mailing Address - Fax:
Practice Address - Street 1:3506 LOCHWOOD DR
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-2995
Practice Address - Country:US
Practice Address - Phone:720-331-4401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-24
Last Update Date:2023-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CO00205593122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program