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General NPI Number Information
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NPI Number | 1144045840
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Entity Type | Organization
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Legal Business Name | AVON DENTAL PLLC
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Dates
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Enumeration Date | 11/18/2024
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Last Update Date | 11/18/2024
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Provider Practice Location Address
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Address Line | 308A BLATTNER DR
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City | AVON
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State | MN
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Zip | 56310-8674
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Country | US
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Telephone | 320-356-7374
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Fax |
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Provider Business Mailing Address
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Address Line | 24183 69TH AVE
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City | SAINT AUGUSTA
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State | MN
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Zip | 56301-8402
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Country | US
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Telephone | 952-686-8444
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | NICOLETTE THERESE PORTTIIN
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Credential | DDS
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Telephone | 952-686-8444
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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