Provider Demographics
NPI:1740377522
Name:PHILLIPS, TRAVIS R (DDS)
Entity type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:R
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:RANDY
Other - Middle Name:
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:502 NORTH WELLS
Mailing Address - Street 2:
Mailing Address - City:EDNA
Mailing Address - State:TX
Mailing Address - Zip Code:77957
Mailing Address - Country:US
Mailing Address - Phone:361-782-2223
Mailing Address - Fax:361-782-0328
Practice Address - Street 1:502 NORTH WELLS
Practice Address - Street 2:
Practice Address - City:EDNA
Practice Address - State:TX
Practice Address - Zip Code:77957
Practice Address - Country:US
Practice Address - Phone:361-782-2223
Practice Address - Fax:361-782-0328
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14114122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist