Healthcare Provider Details

I. General information

NPI: 1619952850
Provider Name (Legal Business Name): TRAVIS A. WITHERINGTON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 06/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 E. DIVISION RD SUITE A-1
OAK RIDGE TN
37830
US

IV. Provider business mailing address

140 E. DIVISION RD SUITE A-1
OAK RIDGE TN
37830
US

V. Phone/Fax

Practice location:
  • Phone: 865-482-5811
  • Fax: 865-482-8686
Mailing address:
  • Phone: 865-482-5811
  • Fax: 865-482-8686

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS0000002349
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: