Healthcare Provider Details

I. General information

NPI: 1700467974
Provider Name (Legal Business Name): TRAVIS DENNIS LPN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2021
Last Update Date: 04/19/2021
Certification Date: 04/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24931 KELLY RD
EASTPOINTE MI
48021-1384
US

IV. Provider business mailing address

4829 NOTTINGHAM RD
DETROIT MI
48224-3425
US

V. Phone/Fax

Practice location:
  • Phone: 586-771-0675
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2472R0900X
TaxonomyRenal Dialysis Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number4703119474
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number4703119474
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: