Provider Demographics
NPI:1104266824
Name:PERRY, TRAVIS EDWARD (DDS)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:EDWARD
Last Name:PERRY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 S 31ST ST
Mailing Address - Street 2:FL 2
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-3506
Mailing Address - Country:US
Mailing Address - Phone:215-925-2400
Mailing Address - Fax:215-925-9162
Practice Address - Street 1:502 CHURCH STREET
Practice Address - Street 2:
Practice Address - City:MOOSIC
Practice Address - State:PA
Practice Address - Zip Code:18507
Practice Address - Country:US
Practice Address - Phone:570-344-3500
Practice Address - Fax:570-344-9442
Is Sole Proprietor?:No
Enumeration Date:2013-06-26
Last Update Date:2020-01-28
Deactivation Date:2019-10-23
Deactivation Code:
Reactivation Date:2020-01-17
Provider Licenses
StateLicense IDTaxonomies
PADS039537122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist