MEDICARE: DR. BERNARD RAY GAVRON DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223E0200X	Endodontics	D1620	NM

General Provider Information

NPI Number	:	1003897182
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BERNARD RAY GAVRON DDS

Provider Business Mailing Address
First Line	:	465 SAINT MICHAELS DR
Second Line	:	STE 208
City	:	SANTA FE
State	:	NM
Zip	:	87505-7670
Country	:	US
Telephone Number	:	505-988-7356
Fax Number	:	505-992-8950

Provider Business Practice Location Address
First Line	:	465 SAINT MICHAELS DR
Second Line	:	STE 208
City	:	SANTA FE
State	:	NM
Zip	:	87505-7670
Country	:	US
Telephone Number	:	505-988-7356
Fax Number	:	505-992-8950

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/07/2005
Last Update Date	:	02/01/2011

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