Healthcare Provider Details

I. General information

NPI: 1205240173
Provider Name (Legal Business Name): TRAVIS BELLICCHI DMD, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2014
Last Update Date: 05/18/2023
Certification Date: 05/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BODIN CIR
TRAVIS AFB CA
94535-1809
US

IV. Provider business mailing address

101 BODIN CIR
TRAVIS AFB CA
94535-1809
US

V. Phone/Fax

Practice location:
  • Phone: 707-423-7052
  • Fax:
Mailing address:
  • Phone: 707-423-7052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number12012188A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: