Provider Demographics
NPI:1548256381
Name:TRAVAGLIATO, CHARLES SEBASTIAN (DDS)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:SEBASTIAN
Last Name:TRAVAGLIATO
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 1:4741 CAMP RD
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075-2603
Mailing Address - Country:US
Mailing Address - Phone:716-646-9423
Mailing Address - Fax:716-646-9429
Practice Address - Street 1:4741 CAMP RD
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:NY
Practice Address - Zip Code:14075-2603
Practice Address - Country:US
Practice Address - Phone:716-646-9423
Practice Address - Fax:716-646-9429
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY35091122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00708681Medicaid