Provider Demographics
NPI:1932706306
Name:TRAVIS, BRENYATTA (DMD)
Entity Type:Individual
Prefix:
First Name:BRENYATTA
Middle Name:
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:991 HIGHWAY 42
Mailing Address - Street 2:
Mailing Address - City:PETAL
Mailing Address - State:MS
Mailing Address - Zip Code:39465-9739
Mailing Address - Country:US
Mailing Address - Phone:601-447-4799
Mailing Address - Fax:
Practice Address - Street 1:28 PASS RD STE 300
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-3244
Practice Address - Country:US
Practice Address - Phone:228-863-4009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-07
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS4169-201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice