Healthcare Provider Details

I. General information

NPI: 1477912806
Provider Name (Legal Business Name): TRAVIS BURNHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2016
Last Update Date: 11/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

959 MYRTLE AVE
EUREKA CA
95501-1219
US

IV. Provider business mailing address

670 9TH ST STE 203
ARCATA CA
95521-6249
US

V. Phone/Fax

Practice location:
  • Phone: 707-442-7078
  • Fax: 707-442-7298
Mailing address:
  • Phone: 707-826-8633
  • Fax: 707-826-8638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number101887
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: