Healthcare Provider Details

I. General information

NPI: 1144045840
Provider Name (Legal Business Name): AVON DENTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2024
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308A BLATTNER DR
AVON MN
56310-8674
US

IV. Provider business mailing address

24183 69TH AVE
SAINT AUGUSTA MN
56301-8402
US

V. Phone/Fax

Practice location:
  • Phone: 320-356-7374
  • Fax:
Mailing address:
  • Phone: 952-686-8444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NICOLETTE THERESE PORTTIIN
Title or Position: PRESIDENT
Credential: DDS
Phone: 952-686-8444