MEDICARE: TRAVIS WILLEY, DDS PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry
2	122300000X	Dentist

General Provider Information

NPI Number	:	1043717382
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRAVIS WILLEY, DDS PC

Provider Business Mailing Address
First Line	:	4745 BOARDWALK DR STE D102
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-3773
Country	:	US
Telephone Number	:	970-223-6101
Fax Number	:

Provider Business Practice Location Address
First Line	:	4745 BOARDWALK DR STE D102
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-3773
Country	:	US
Telephone Number	:	970-223-6101
Fax Number	:	970-530-1593

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	TERESA VENEKAMP
Credential	:
Telephone Number	:	970-223-6101

Provider Enumeration Date	:	04/12/2018
Last Update Date	:	04/12/2018

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