Provider Demographics
NPI:1932217908
Name:MAXWELL, TRAVIS (DMD)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:MAXWELL
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 1:4233 LAKECREST DR
Mailing Address - Street 2:
Mailing Address - City:GUNTERSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35976-7558
Mailing Address - Country:US
Mailing Address - Phone:256-582-1189
Mailing Address - Fax:
Practice Address - Street 1:4233 LAKECREST DR
Practice Address - Street 2:
Practice Address - City:GUNTERSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35976-7558
Practice Address - Country:US
Practice Address - Phone:256-582-1189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL34381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice