Provider Demographics
NPI:1457418360
Name:WILLS, TRAVIS MCKENZIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:MCKENZIE
Last Name:WILLS
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 121
Mailing Address - Street 2:
Mailing Address - City:OAK HILL
Mailing Address - State:WV
Mailing Address - Zip Code:25901-0121
Mailing Address - Country:US
Mailing Address - Phone:304-469-4911
Mailing Address - Fax:304-469-4270
Practice Address - Street 1:96 LAMPLIGHTER ST
Practice Address - Street 2:
Practice Address - City:OAK HILL
Practice Address - State:WV
Practice Address - Zip Code:25901-9512
Practice Address - Country:US
Practice Address - Phone:304-469-4911
Practice Address - Fax:304-469-4270
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3532122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV4005081000Medicaid