Provider Demographics
NPI:1902150352
Name:LUDY, TRAVIS DAN (DDS)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:DAN
Last Name:LUDY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6154 DUTCH FORK ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-4744
Mailing Address - Country:US
Mailing Address - Phone:907-841-0572
Mailing Address - Fax:
Practice Address - Street 1:1135 VITALITY DR STE 130
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89011-4809
Practice Address - Country:US
Practice Address - Phone:702-359-7401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-07
Last Update Date:2024-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62986122300000X
NVS7-1431223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist