Healthcare Provider Details

I. General information

NPI: 1467884395
Provider Name (Legal Business Name): TRAVIS JONATHAN VERTOLLI DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2013
Last Update Date: 08/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BUILDING H100 SANTA MARGARITA ROAD
CAMP PENDLETON CA
92055
US

IV. Provider business mailing address

6 BRITTANY LN
MILLVILLE NJ
08332-7261
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-8882
  • Fax: 760-725-1267
Mailing address:
  • Phone: 856-364-0304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: