MEDICARE: TRAVIS PRUNTY DDS PLLC

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	261QD0000X	Dental Clinic/Center	D12552	MN

General Provider Information

NPI Number	:	1235395476
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRAVIS PRUNTY DDS PLLC

Provider Business Mailing Address
First Line	:	PO BOX 894
Second Line	:
City	:	MANKATO
State	:	MN
Zip	:	56002-0894
Country	:	US
Telephone Number	:	507-388-3023
Fax Number	:	507-388-3353

Provider Business Practice Location Address
First Line	:	730 E MADISON AVE
Second Line	:
City	:	MANKATO
State	:	MN
Zip	:	56001-6100
Country	:	US
Telephone Number	:	507-388-3023
Fax Number	:	507-388-3353

Authorized Official
Title or Position	:	DDS
Name	:	DR. TRAVIS ANDREW PRUNTY
Credential	:
Telephone Number	:	507-388-3023

Provider Enumeration Date	:	08/06/2008
Last Update Date	:	08/06/2008

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