MEDICARE: TRAVERS DENTAL GROUP INCORPORATED

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
2	1223G0001X	General Practice Dentistry

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	61514	OTHER	CA	DENTIST

General Provider Information

NPI Number	:	1457026015
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRAVERS DENTAL GROUP INCORPORATED

Provider Business Mailing Address
First Line	:	828 JACKMAN ST
Second Line	:
City	:	EL CAJON
State	:	CA
Zip	:	92020-3053
Country	:	US
Telephone Number	:	312-342-2299
Fax Number	:

Provider Business Practice Location Address
First Line	:	828 JACKMAN ST
Second Line	:
City	:	EL CAJON
State	:	CA
Zip	:	92020-3053
Country	:	US
Telephone Number	:	312-342-2299
Fax Number	:

Authorized Official
Title or Position	:	OWNER DENTIST
Name	:	DR. GRACE TRAVERS
Credential	:	DDS
Telephone Number	:	312-342-2299

Provider Enumeration Date	:	08/14/2021
Last Update Date	:	11/16/2021

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