Provider Demographics
NPI:1922137447
Name:AVON DENTAL CLINIC PA
Entity Type:Organization
Organization Name:AVON DENTAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RECEPTIONIST
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:A
Authorized Official - Last Name:KALIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-356-7374
Mailing Address - Street 1:308A BLATTNER DRIVE
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:MN
Mailing Address - Zip Code:56310
Mailing Address - Country:US
Mailing Address - Phone:320-356-7374
Mailing Address - Fax:320-356-9427
Practice Address - Street 1:308A BLATTNER DRIVE
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:MN
Practice Address - Zip Code:56310
Practice Address - Country:US
Practice Address - Phone:320-356-7374
Practice Address - Fax:320-356-9427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND109621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty