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General NPI Number Information
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NPI Number | 1477781813
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Entity Type | Individual
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Provider Name | TRAVIS L EDWARDS D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 06/24/2009
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Last Update Date | 06/29/2022
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Provider Practice Location Address
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Address Line | 4106 WAKE FOREST RD STE 201
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City | RALEIGH
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State | NC
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Zip | 27609-6397
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Country | US
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Telephone | 919-277-0577
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Fax | 919-390-0019
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Provider Business Mailing Address
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Address Line | 351 W IOWA AVE
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City | NAMPA
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State | ID
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Zip | 83686-2856
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Country | US
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Telephone | 208-461-2600
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D-4211
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 12792
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License Number State | NC
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Taxonomy #3
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 12792
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License Number State | NC
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