Provider Demographics
NPI:1699764431
Name:GAVREN, BETH ANN (DDS)
Entity type:Individual
Prefix:DR
First Name:BETH
Middle Name:ANN
Last Name:GAVREN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15785 95TH AVE N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-4404
Mailing Address - Country:US
Mailing Address - Phone:763-233-4141
Mailing Address - Fax:763-420-5875
Practice Address - Street 1:15785 95TH AVE N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4404
Practice Address - Country:US
Practice Address - Phone:763-233-4141
Practice Address - Fax:763-420-5875
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND114631223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN8068330-00Medicaid
MN8068330-00Medicaid