=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679878938
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRAVIS M. SORENSEN DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2011
-----------------------------------------------------
Last Update Date | 05/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 625 E 500 S STE 204
-----------------------------------------------------
City | BOUNTIFUL
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84010-3883
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-298-2242
-----------------------------------------------------
Fax | 801-294-9920
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 625 E 500 S STE 204
-----------------------------------------------------
City | BOUNTIFUL
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84010-3883
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-298-2242
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 9349
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 6492
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 12396150
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------