Healthcare Provider Details

I. General information

NPI: 1033313960
Provider Name (Legal Business Name): GERALYN TRAVIA RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2669 N SWAN BLVD
MILWAUKEE WI
53226-1800
US

IV. Provider business mailing address

2669 N SWAN BLVD
MILWAUKEE WI
53226-1800
US

V. Phone/Fax

Practice location:
  • Phone: 414-258-2216
  • Fax:
Mailing address:
  • Phone: 414-258-2216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number5674-016
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: