Healthcare Provider Details

I. General information

NPI: 1699983833
Provider Name (Legal Business Name): PHILIP RAY TRAVIS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2007
Last Update Date: 12/07/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3015 WILSON AVE
LOUISVILLE KY
40211-1969
US

IV. Provider business mailing address

3015 WILSON AVE
LOUISVILLE KY
40211-1969
US

V. Phone/Fax

Practice location:
  • Phone: 502-774-4401
  • Fax: 502-772-4783
Mailing address:
  • Phone: 502-774-4401
  • Fax: 502-772-4783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6111
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: