Provider Demographics
NPI:1609993278
Name:WILLE, TRAVIS WILLIAM (DDS, MS)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:WILLIAM
Last Name:WILLE
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 LAKE ST N
Mailing Address - Street 2:SUITE #100
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-2513
Mailing Address - Country:US
Mailing Address - Phone:651-464-8065
Mailing Address - Fax:651-464-5432
Practice Address - Street 1:69 LAKE ST N
Practice Address - Street 2:SUITE #100
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-2513
Practice Address - Country:US
Practice Address - Phone:651-464-8065
Practice Address - Fax:651-464-5432
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN115521223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics