Healthcare Provider Details

I. General information

NPI: 1295733913
Provider Name (Legal Business Name): J SCOTT TRAVELSTEAD DMD, PC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1823 NW KINGS BLVD
CORVALLIS OR
97330-1907
US

IV. Provider business mailing address

1823 NW KINGS BLVD
CORVALLIS OR
97330-1907
US

V. Phone/Fax

Practice location:
  • Phone: 541-754-6400
  • Fax: 541-758-2081
Mailing address:
  • Phone: 541-754-6400
  • Fax: 541-758-2081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD7300
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD7300
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: