Provider Demographics
NPI:1841229598
Name:FIFTH AVENUE DENTAL, P.A.
Entity Type:Organization
Organization Name:FIFTH AVENUE DENTAL, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:R
Authorized Official - Last Name:DONLIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-421-5320
Mailing Address - Street 1:1829 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:ANOKA
Mailing Address - State:MN
Mailing Address - Zip Code:55303-2566
Mailing Address - Country:US
Mailing Address - Phone:763-421-5320
Mailing Address - Fax:763-421-2677
Practice Address - Street 1:1829 5TH AVE
Practice Address - Street 2:
Practice Address - City:ANOKA
Practice Address - State:MN
Practice Address - Zip Code:55303-2566
Practice Address - Country:US
Practice Address - Phone:763-421-5320
Practice Address - Fax:763-421-2677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND49101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty