Provider Demographics
NPI:1962859058
Name:AVERA MARSHALL
Entity Type:Organization
Organization Name:AVERA MARSHALL
Other - Org Name:AVERA MEDICAL GROUP DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:STREIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-537-9160
Mailing Address - Street 1:197 N TYLER ST
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:MN
Mailing Address - Zip Code:56178-1160
Mailing Address - Country:US
Mailing Address - Phone:507-247-5591
Mailing Address - Fax:
Practice Address - Street 1:197 N TYLER ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:MN
Practice Address - Zip Code:56178-1160
Practice Address - Country:US
Practice Address - Phone:507-247-5591
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AVERA MARSHALL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-18
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NOT ASSIGNED YETOtherNOT ASSIGNED YET