Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | D1620 | NM |
NPI | 1003897182 |
---|---|
Provider Name | Dr. Bernard Ray Gavron |
First Address | Santa Fe, NM 87505-7670 |
Second Address | Santa Fe, NM 87505-7670 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/11/2005 |
Last Update Date | 01/02/2011 |