Individual
DR. RANDOLPH THOMAS TRAVIS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DMD
Contact information
Practice address
1400 PRIDE AVENUE, MADISONVILLE, KY 42431-9108
(270) 821-7386
(270) 821-7401
Mailing address
1400 PRIDE AVENUE, MADISONVILLE, KY 42431-9108
(270) 821-7386
(270) 821-7401
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
5141
KY
1223P0221X
Pediatric Dentistry
INDIANA 12010320A
KY
1223P0221X
Pediatric Dentistry
Primary
KY. 5141
KY
1223P0221X
Pediatric Dentistry
OHIO 30.019661
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200265680 A
—
IN
01
—
45608965
EPSDT
KY
05
—
600-51414
—
KY
Enumeration date
07/31/2006
Last updated
06/12/2008
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