Healthcare Provider Details

I. General information

NPI: 1043717382
Provider Name (Legal Business Name): TRAVIS WILLEY, DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2018
Last Update Date: 04/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4745 BOARDWALK DR STE D102
FORT COLLINS CO
80525-3773
US

IV. Provider business mailing address

4745 BOARDWALK DR STE D102
FORT COLLINS CO
80525-3773
US

V. Phone/Fax

Practice location:
  • Phone: 970-223-6101
  • Fax: 970-530-1593
Mailing address:
  • Phone: 970-223-6101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: TERESA VENEKAMP
Title or Position: OFFICE MANAGER
Credential:
Phone: 970-223-6101