Healthcare Provider Details

I. General information

NPI: 1700260734
Provider Name (Legal Business Name): TRAVIS HADDAD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2015
Last Update Date: 05/29/2025
Certification Date: 05/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8326 N SAGINAW RD
MOUNT MORRIS MI
48458-1648
US

IV. Provider business mailing address

3213 ROCHESTER RD
ROYAL OAK MI
48073-3553
US

V. Phone/Fax

Practice location:
  • Phone: 810-687-5040
  • Fax: 810-687-5130
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901021563
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: