Provider Demographics
NPI:1992715304
Name:BOYER, TRAVIS (DMD)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:BOYER
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 1:332 S ORCHARD SPRINGS DR STE 110
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-6154
Mailing Address - Country:US
Mailing Address - Phone:719-924-8858
Mailing Address - Fax:
Practice Address - Street 1:716 YELLOWSTONE AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4407
Practice Address - Country:US
Practice Address - Phone:208-478-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD38961223G0001X
CO002027901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807402500Medicaid
CO07178506Medicaid
OK200533690AMedicaid
ID807402500Medicaid