Healthcare Provider Details

I. General information

NPI: 1922137447
Provider Name (Legal Business Name): AVON DENTAL CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 11/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308A BLATTNER DRIVE
AVON MN
56310
US

IV. Provider business mailing address

308A BLATTNER DRIVE
AVON MN
56310
US

V. Phone/Fax

Practice location:
  • Phone: 320-356-7374
  • Fax: 320-356-9427
Mailing address:
  • Phone: 320-356-7374
  • Fax: 320-356-9427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD10962
License Number StateMN

VIII. Authorized Official

Name: CHERYL A KALIS
Title or Position: RECEPTIONIST
Credential:
Phone: 320-356-7374