Healthcare Provider Details

I. General information

NPI: 1881961779
Provider Name (Legal Business Name): TRAVIS CHRISTOPH FAGALA DENTURIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2011
Last Update Date: 11/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 S 2ND AVE
WALLA WALLA WA
99362-3002
US

IV. Provider business mailing address

217 S 2ND AVE
WALLA WALLA WA
99362-3002
US

V. Phone/Fax

Practice location:
  • Phone: 509-525-7250
  • Fax: 509-526-5295
Mailing address:
  • Phone: 509-525-7250
  • Fax: 509-526-5295

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License NumberDN 60208462
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: