Provider Demographics
NPI:1891313300
Name:SHORE, TRAVIS (DMD)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:SHORE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1137 SENTINEL PEAK RD
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-1496
Mailing Address - Country:US
Mailing Address - Phone:509-844-5518
Mailing Address - Fax:
Practice Address - Street 1:1993 FRONTAGE RD STE 208
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-4695
Practice Address - Country:US
Practice Address - Phone:520-458-4646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-10
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZPD00231223G0001X
AZD0107741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice