Provider Demographics
NPI:1932203502
Name:DALE K TRAVIS DDS PS
Entity Type:Organization
Organization Name:DALE K TRAVIS DDS PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:TRAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:425-483-5959
Mailing Address - Street 1:PO BOX 606
Mailing Address - Street 2:
Mailing Address - City:WOODINVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98072
Mailing Address - Country:US
Mailing Address - Phone:425-483-5959
Mailing Address - Fax:425-806-5440
Practice Address - Street 1:17416 135TH AVE NE
Practice Address - Street 2:STE 201
Practice Address - City:WOODINVILLE
Practice Address - State:WA
Practice Address - Zip Code:98072
Practice Address - Country:US
Practice Address - Phone:425-483-5959
Practice Address - Fax:425-806-5440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00005037122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty