Provider Demographics
NPI:1306967633
Name:BEAVER, HARRION ALEXANDER (DMD)
Entity type:Individual
Prefix:
First Name:HARRION
Middle Name:ALEXANDER
Last Name:BEAVER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3434 ATLANTIC BLVD STE 7
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-2076
Mailing Address - Country:US
Mailing Address - Phone:904-396-1758
Mailing Address - Fax:904-396-4924
Practice Address - Street 1:3434 ATLANTIC BLVD STE 7
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-2076
Practice Address - Country:US
Practice Address - Phone:904-396-1758
Practice Address - Fax:904-396-4924
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN152611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL593719802OtherTAX ID NUMBER