Healthcare Provider Details

I. General information

NPI: 1740377522
Provider Name (Legal Business Name): TRAVIS R PHILLIPS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: RANDY PHILLIPS

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 NORTH WELLS
EDNA TX
77957
US

IV. Provider business mailing address

502 NORTH WELLS
EDNA TX
77957
US

V. Phone/Fax

Practice location:
  • Phone: 361-782-2223
  • Fax: 361-782-0328
Mailing address:
  • Phone: 361-782-2223
  • Fax: 361-782-0328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number14114
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: