Provider Demographics
NPI:1295949170
Name:LIERLY, TRAVIS W (DDS)
Entity type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:W
Last Name:LIERLY
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 1:10001 S PENNSYLVANIA AVE
Mailing Address - Street 2:BLDG. P SUITE 130
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73159-6923
Mailing Address - Country:US
Mailing Address - Phone:405-691-6831
Mailing Address - Fax:405-691-2704
Practice Address - Street 1:10001 S PENNSYLVANIA AVE
Practice Address - Street 2:BLDG. P SUITE 130
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-6923
Practice Address - Country:US
Practice Address - Phone:405-691-6831
Practice Address - Fax:405-691-2704
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK44791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice