Provider Demographics
NPI:1558521955
Name:BEAVEN, TJARK RYAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:TJARK
Middle Name:RYAN
Last Name:BEAVEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13456 VIA VARRA RD
Mailing Address - Street 2:APT. #131
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-9001
Mailing Address - Country:US
Mailing Address - Phone:631-949-5585
Mailing Address - Fax:
Practice Address - Street 1:14807 W 64TH AVE
Practice Address - Street 2:SUITE C
Practice Address - City:ARVADA
Practice Address - State:CO
Practice Address - Zip Code:80007-0104
Practice Address - Country:US
Practice Address - Phone:303-456-4095
Practice Address - Fax:303-484-2596
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO99151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice