MEDICARE: DR. MARY KATHERINE GAVRI DMD

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	1223G0001X	General Practice Dentistry	8545	SC
2	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	8545	SC
3	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	36717	TX

General Provider Information

NPI Number	:	1497124556
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY KATHERINE GAVRI DMD

Provider Business Mailing Address
First Line	:	3788 RICHMOND AVE APT 1468
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77046-3719
Country	:	US
Telephone Number	:	757-903-1671
Fax Number	:

Provider Business Practice Location Address
First Line	:	104 W 12TH ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77008-6990
Country	:	US
Telephone Number	:	713-861-4000
Fax Number	:

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

Provider Enumeration Date	:	09/18/2015
Last Update Date	:	04/09/2021

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