Basic Information
| Provider Information | |||||||||
| NPI: | 1558521955 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEAVEN | ||||||||
| FirstName: | TJARK | ||||||||
| MiddleName: | RYAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13456 VIA VARRA RD | ||||||||
| Address2: | APT. #131 | ||||||||
| City: | BROOMFIELD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800209001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6319495585 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 14807 W 64TH AVE | ||||||||
| Address2: | SUITE C | ||||||||
| City: | ARVADA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800070104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034564095 | ||||||||
| FaxNumber: | 3034842596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2008 | ||||||||
| LastUpdateDate: | 06/02/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 9915 | CO | Y | Dental Providers | Dentist | General Practice |
No ID Information.