Healthcare Provider Details

I. General information

NPI: 1730679168
Provider Name (Legal Business Name): TRAVIS C. BRISENO LD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2018
Last Update Date: 05/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

773 GOLF VIEW DR
MEDFORD OR
97504
US

IV. Provider business mailing address

6950 NE CAMPUS WAY
HILLSBORO OR
97124-5611
US

V. Phone/Fax

Practice location:
  • Phone: 855-433-6825
  • Fax: 503-952-2267
Mailing address:
  • Phone: 855-433-6825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License NumberDT-TMP-10190928
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: