1124681564 NPI number — TRAVIS L KENDALL DDS PLLC

Table of content: DR. JUDY CAMILLE MILAKOVICH PHD (NPI 1598717134)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124681564 NPI number — TRAVIS L KENDALL DDS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRAVIS L KENDALL DDS PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
TEXAS SEDATION DENTAL & IMPLANT CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124681564
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/11/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
444 FOREST SQ STE E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONGVIEW
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75605-4463
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-758-5551
Provider Business Mailing Address Fax Number:
903-758-5877

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
444 FOREST SQ STE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONGVIEW
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75605-4463
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-758-5551
Provider Business Practice Location Address Fax Number:
903-758-5877
Provider Enumeration Date:
04/22/2019

Additional Information

Authorized Official

Authorized Official Last Name:
KENDALL
Authorized Official First Name:
TRAVIS
Authorized Official Middle Name:
LANE
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
903-758-5551

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QD0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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