Provider Demographics
NPI:1376303503
Name:HILL AVENUE DENTAL LLC
Entity Type:Organization
Organization Name:HILL AVENUE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:LUCAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-577-6367
Mailing Address - Street 1:907 N ANKENY BLVD
Mailing Address - Street 2:
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50023-4002
Mailing Address - Country:US
Mailing Address - Phone:515-577-6367
Mailing Address - Fax:
Practice Address - Street 1:1510 HILL AVE STE D
Practice Address - Street 2:
Practice Address - City:SPIRIT LAKE
Practice Address - State:IA
Practice Address - Zip Code:51360-1676
Practice Address - Country:US
Practice Address - Phone:712-336-4895
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VIDENTA, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-03-22
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty