Provider Demographics
NPI:1700467974
Name:DENNIS, TRAVIS (LPN)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:DENNIS
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4829 NOTTINGHAM RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-3425
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24931 KELLY RD
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-1384
Practice Address - Country:US
Practice Address - Phone:586-771-0675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2472R0900X, 126800000X
MI4703119474164X00000X, 164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No2472R0900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherRenal Dialysis
No164X00000XNursing Service ProvidersLicensed Vocational Nurse
No126800000XDental ProvidersDental Assistant