MEDICARE: DR. TRAVIS WALDING D.D.S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	29926	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	29926	OTHER	TX	DENTAL LICENSE NUMBER

General Provider Information

NPI Number	:	1164835039
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TRAVIS WALDING D.D.S

Provider Business Mailing Address
First Line	:	2401 FOUNTAIN VIEW DR
Second Line	:	SUITE 106
City	:	HOUSTON
State	:	TX
Zip	:	77057-4827
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2401 FOUNTAIN VIEW DR
Second Line	:	SUITE 106
City	:	HOUSTON
State	:	TX
Zip	:	77057-4827
Country	:	US
Telephone Number	:	713-266-2265
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/08/2014
Last Update Date	:	06/08/2014

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