MEDICARE: DR. TRAVIS ANDREW PRUNTY DDS

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	122300000X	Dentist	12552	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275685190
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TRAVIS ANDREW PRUNTY DDS

Provider Business Mailing Address
First Line	:	730 MADISON AVE
Second Line	:
City	:	MANKATO
State	:	MN
Zip	:	56001-6100
Country	:	US
Telephone Number	:	507-388-3023
Fax Number	:	507-388-3353

Provider Business Practice Location Address
First Line	:	730 MADISON AVE
Second Line	:
City	:	MANKATO
State	:	MN
Zip	:	56001-6100
Country	:	US
Telephone Number	:	507-388-3023
Fax Number	:	507-388-3353

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/18/2007
Last Update Date	:	01/18/2017

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