Healthcare Provider Details

I. General information

NPI: 1861976839
Provider Name (Legal Business Name): TRAVIS ANDRE RUSSELL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2018
Last Update Date: 02/20/2026
Certification Date: 02/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 CONCORD PKWY S STE 110A
CONCORD NC
28027-2704
US

IV. Provider business mailing address

300 MOORESVILLE RD
KANNAPOLIS NC
28081-0304
US

V. Phone/Fax

Practice location:
  • Phone: 704-920-1070
  • Fax: 704-920-1071
Mailing address:
  • Phone: 704-920-1070
  • Fax: 704-920-1071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number9255
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: