Healthcare Provider Details

I. General information

NPI: 1699764431
Provider Name (Legal Business Name): BETH ANN GAVREN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 06/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15785 95TH AVE N
MAPLE GROVE MN
55369-4404
US

IV. Provider business mailing address

15785 95TH AVE N
MAPLE GROVE MN
55369-4404
US

V. Phone/Fax

Practice location:
  • Phone: 763-233-4141
  • Fax: 763-420-5875
Mailing address:
  • Phone: 763-233-4141
  • Fax: 763-420-5875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD11463
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: