Provider Demographics
NPI:1982808291
Name:BURKETT, TRAVIS DEAN (DDS)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:DEAN
Last Name:BURKETT
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 712
Mailing Address - Street 2:
Mailing Address - City:DRUMRIGHT
Mailing Address - State:OK
Mailing Address - Zip Code:74030-0712
Mailing Address - Country:US
Mailing Address - Phone:918-352-3312
Mailing Address - Fax:918-352-2681
Practice Address - Street 1:1226 W BROADWAY
Practice Address - Street 2:
Practice Address - City:DRUMRIGHT
Practice Address - State:OK
Practice Address - Zip Code:74030
Practice Address - Country:US
Practice Address - Phone:918-352-3312
Practice Address - Fax:918-352-2681
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5939122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist