Healthcare Provider Details

I. General information

NPI: 1982433181
Provider Name (Legal Business Name): WARREN TRAVIS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2024
Last Update Date: 07/29/2024
Certification Date: 07/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 E DUPONT RD STE D
FORT WAYNE IN
46825-1546
US

IV. Provider business mailing address

2121 E DUPONT RD STE D
FORT WAYNE IN
46825-1546
US

V. Phone/Fax

Practice location:
  • Phone: 260-338-2643
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number12013681A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: