Provider Demographics
NPI:1568615292
Name:BEAVIN, JENNIFER LYNN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LYNN
Last Name:BEAVIN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 FETTER AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217-2233
Mailing Address - Country:US
Mailing Address - Phone:502-724-0397
Mailing Address - Fax:
Practice Address - Street 1:1976 DOUGLASS BLVD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-1826
Practice Address - Country:US
Practice Address - Phone:502-454-7627
Practice Address - Fax:502-384-8203
Is Sole Proprietor?:No
Enumeration Date:2008-10-26
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS00000088181223G0001X
KY86321223G0001X
IN12011286A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice